Benedictine Living Community Mother of Mercy

Inspectors wroteBased on interview and document review, the facility failed to ensure a placed peripheral insertion central catheter (PICC) line was monitored and recorded in the medical record to ensure continuity of care in accordance with current standards of care for 1 of 1 resident (R1) reviewed for PICC care. R1 had a PICC line in place for over 30 days at the care center but the measurement from insertion to catheter hub (used to determine if the line is migrating) was not consistently tracked or recorded. This could delay identification of line migration or contribute to associated complications (i.e., thrombosis, vessel perforation, catheter dysfunction).

Inspectors wroteBased on interview and document review the facility failed to implement interventions to reduce the risk of falls for 1 of 3 residents (R1) reviewed for accidents and supervision. R1's care plan directed bed mobility with assistance of two staff. On 5/4/26, R1 fell out of her bed while one staff provided cares without assistance. This resulted in R1's left hip fracture, pain, and fear. The immediate jeopardy (IJ) began on 5/4/26 when nursing assistant (NA)-A provided cares, including bed mobility, without the assistance of another staff person. R1's care plan, dated 4/28/26, directed assistance of two staff for bed mobility. The IJ was removed on 5/5/26 when the facility provided education to staff regarding following care plans, audits to monitor staff performance and policy review. [...]

Inspectors wroteBased on observation, interview and document review the facility failed to develop the care plan for 1 of 3 residents (R3) reviewed for care plans when R3's care sheet directed staff to transfer with a full body mechanical lift, but the staff transferred her with a mechanical standing lift.

Inspectors wroteBased on observation, interview and document review, the facility failed to assess the independent use of an electric lift chair for 1 of 3 residents (R1) reviewed for accidents. This resulted in actual harm when R1 attempted to self-transfer from the lift chair, fell, hit her head, and sustained a hematoma (a collection of blood in the tissues after an injury) and laceration of the forehead, sent to the emergency department (ED) for further evaluation, wound care, pain control, and received four stitches to the right forehead. R1 sustained an additional fall from a wheel chair, hit her head, sustained a hematoma to right lateral proximal (point of attachment) hip, sent to ED for further evaluation and pain control. The facility implemented corrective action, so the deficient practice was issued at past non-compliance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were properly stored, labeled, dated and discarded properly. Additionally, the facility failed to ensure 1 refrigerator in the kitchen and 2 of 3-unit refrigerators were adequately monitored for temperature and food quality to reduce the risk of complications or illness. These findings had the potential to affect all 56 residents within the care center.

Inspectors wroteBased on interview and record review the facility failed to ensure Notice of Medicare Non-Coverage (NOMNC) and Advanced Beneficiary Notice (ABN) was given to residents whose Medicare part A services were ending for 2 of 3 residents (R73, R48) who were reviewed for NOMNC and ABN notices.

Inspectors wroteBased on record review, and interview, the facility failed to conduct care conferences for 1 of 2 residents (R27) reviewed for care planning.

Inspectors wroteBased on record review and interview the facility failed to ensure medications were available for administration per physician order for 1 of 1 resident (R64) reviewed for pharmaceutical services.

Inspectors wroteBased on observation, interview and document review, the facility failed to properly sanitize a shared glucometer after use on 1 of 1 residents (R71), reviewed for blood sugar monitoring.

Inspectors wroteBased on interview and document review, the facility failed to monitor and implement interventions for heart failure for 2 of 2 residents (R33, R43) reviewed. This resulted in actual harm to R33 who was re-hospitalized for exacerbation of heart failure.

Inspectors wroteBased on record review and interviews the facility failed to ensure the required staffing information was posted daily. This had the potential to affect all 57 residents residing in the facility and their visitors who may wish to view the information.

Inspectors wroteBased on interview and record review the facility failed to conduct and document a comprehensive facility-wide assessment which included all of the necessary components to provide adequate care and services to the residents in the facility. The deficient practice had the potential to affect all 57 residents in the facility.

Inspectors wroteBased on interview and document review the facility failed to maintain a Quality Assurance Assessment/ Quality Assurance and Performance Improvement (QAA/QAPI) program that was effective in identifying, assessing, performing, developing and implementing appropriate plans of action to assure clinical care, quality of care, resident rights and services were identified to maintain acceptable levels of performance. Furthermore, the facility failed to conduct ongoing quality assessment and assurance activities, develop, and implement appropriate plans of action to correct repeated quality deficiencies identified during the survey the facility was aware of or should have been aware of which had the potential to adversely affect all 57 residents which resided in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure changes in medication were communicated to 1 of 1 residents (R33) reviewed for notification of change in medications.

Inspectors wroteBased on interview and document review, the facility failed to ensure advanced directives for emergency care and treatment were accurately reflected in all areas of the medical chart to ensure resident wishes would be implemented correctly in an emergent situation for 1 of 24 residents (R13) reviewed for advanced directives.

Inspectors wroteBased on interview and document review, the facility failed to notify and consult provider for 2 of 2 residents (R33, R43) reviewed for heart failure monitoring.

Inspectors wroteBased on interview and document review, the facility failed to provide a written notice of a bed-hold at the time of transfer for two hospitalizations for 1 of 2 residents (R33) reviewed for hospitalization.

Inspectors wroteBased on interview and document review, the facility failed to complete and transmit a discharge return not anticipated Minimum Data Set (MDS) for 2 of 2 residents (R25, R48) reviewed for transmission of resident assessment.

Inspectors wroteBased on interview and document review, the facility failed to revise the comprehensive care plan for 2 of 2 residents (R33, R43) reviewed for heart failure.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure appropriate hand hygiene for 2 of 4 staff observed for medication pass. Further, the facility failed to ensure 1 of 1 staff consistently followed infection control standards of practice for handling soiled clothing to reduce the risk of infection. This practice had the potential to affect all 57 residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to provide pneumococcal vaccine in a timely manner to 1 of 5 residents (R45) reviewed for immunizations.

Inspectors wroteBased on interviews and document review, the facility failed to contact the resident's physician of missed administration of medication for 1 of 1 resident (R2) reviewed for medication errors. The missed administration of medication resulted in a critical low potassium level of 2.4 mmol/L (millimoles per liter) (normal range 3.5 - 5.1 mmol/L).

Inspectors wroteBased on interview and document review, the facility failed to ensure potassium was available, administered timely and administered as prescribed by the physician for 1 of 1 resident (R2). R2 missed 10 doses of potassium resulting in a critical low potassium level of 2.4 mmol/L (millimoles per liter) (normal range 3.5 - 5.1 mmol/L) requiring IV potassium. R2 was asymptomatic and stable.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure infection control mitigation processes were timely and effectively implemented prior to, and during, facility demolition and renovations. In addition, the facility failed to hire a licensed, and certified contractor, to oversee the construction. This had the potential to impact all 51 residents within the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure necessary care and services were provided to 1 of 1 resident (R1), whose severe environmental allergies were not adequately addressed to ensure she was comfortable and sufficiently protected from preventable allergy reactions. Additionally, when facility renovations were started, adequate barriers to prevent debris and chemical pollution from leaving the construction area were not maintained to protect R1.

Inspectors wroteBased on interview and document review the facility failed to report an allegation of abuse timely (with in two hours) to the State Agency for 1 of 1 resident (R2) reviewed for allegations of physical abuse.

Inspectors wroteBased on interview and document review, the facility failed to have an updated policy on abuse reporting that addressed reporting all incidents of abuse within 2 hours of the allegation. This had the potential to affect all residents that reside at this facility.

Inspectors wroteBased on interview and document review the facility failed to have 8 hours of consecutive registered nursing coverage on a daily basis. This had the potential to affect all 54 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain temperature logs for refrigerators and food served. This had the potential to affect all 54 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to submit the payroll-based journal system (PB&J) staffing data to Centers for Medicare and Medicaid Services (CMS). This had the potential to affect all 54 residents residing in the facility.

Inspectors wroteBased on interview and document review, the faciilty failed to notify the resident's physician of omitted medications, reason for medication omissions, and abnormal blood sugars for 1 of 2 residents (R44) reviewed for insulin.