Our Lady of Prompt Succor Nursing Facility

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision and toileting assistance according to the resident's assessed needs in the plan of care to prevent accidents for 1 (#2) out of 3 (#1, #2, #3) sampled residents. This deficient practice resulted in a harm on 05/23/2026 at 4:00 a.m. when S7CNA failed to assist Resident #2 with a transfer to the toilet. As a result, the resident fell prior to getting to the toilet. The resident was transferred to a local hospital emergency room on [DATE] at 1:22 a.m. An x-ray was performed on 05/24/2026 at 9:52 a.m. with findings of a left impacted femoral neck fracture. The resident was admitted to the hospital and underwent a percutaneous screw fixation of left femoral neck fracture on 05/26/2026.

Inspectors wroteBased on observations and interview, the facility failed to ensure staffing information that was posted daily was accurate and current. The facility's census was 112.

Inspectors wroteBased on record reviews, policy review, personnel file review, and interviews, the facility failed to treat each resident with respect and dignity in a manner and in an environment that promotes maintenance of his or her quality of life for 1 (#44) out of a finalized sample of 38 residents.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that an injury of unknown origin was reported immediately, but not later than two (2) hours to State Survey Agency after discovering or learning of the injury for 1 (#10) of 5 residents (#5, #8 #10, #74, #98) investigated for accidents.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that an injury of unknown origin was reported immediately, but not later than two (2) hours to State Survey Agency after discovering or learning of the injury for 1 (Resident #1) of 3 (Residents #1, #2, #3) sampled residents. The deficient practice had the potential to affect a total census of 126 residents.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to implement a comprehensive person-centered plan of care and follow physician's orders for 2 (Resident #3 and Resident #74) out of 38 sampled residents as evidenced by failing to: 1. implement the comprehensive plan of care for keeping the resident's call light in reach and bed in the lowest position for Resident #3, and2. implement the comprehensive plan and physician's order for two person assistance when transferring Resident #74.

Inspectors wroteBased on observation, record review and interviews, the facility failed to maintain an accurately documented medical record in accordance with accepted professional standards and practices as evidenced by failing to accurately document the use of a CPAP (Continuous Positive Airway Pressure) machine in the resident's EHR (Electronic Health Record) for 1 (#16) out of a census of 112 residents.

Inspectors wroteBased on observations, interviews and record and policy review, the facility failed to maintain an effective infection prevention and control program, by failing to ensure:1. Staff wore appropriate Personal Protective Equipment (PPE) while providing incontinence care to a resident on enhanced barrier precautions (EBP) for Resident #39; and 2. Resident #63's urinary catheter drainage bag avoided contact with the floor.

Inspectors wroteBased on observations, record review, and interview, the facility failed to ensure that medications were stored and labeled properly in accordance with current accepted professional principles by: 1. having loose medications at the bottom of a drawer in the medication cart; and 2. staff failing to conduct and record daily temperature on the medication refrigerator in the medication storage room.

Inspectors wroteBased on observations, record review and interview, the facility failed to store food in accordance with professional standards for food service safely as evidenced by the nursing staff failing to conduct and record daily temperatures for the resident snack/supplement refrigerator in the medication storage room.

Inspectors wroteBased on interview, observations, and record review, the facility failed to ensure a resident was treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of his or her own quality of life by failing to apply a privacy cover to an indwelling catheter urinary drainage bag for 1 (#37) of 32 sampled residents.

Inspectors wroteBased on observations, interview and record review the facility failed to assess 1 (#55) of 1 (#55) residents investigated to self -administer medication out of a finalized sample of 32 residents. The right to self-administer medications was the responsibility of the interdisciplinary team to assess and determine that this practice was clinically appropriate.

Inspectors wroteBased on record review and interview, the facility failed to accurately code the resident's Minimum Data Set (MDS) assessment for antibiotic use for 1 (#65) of 32 sampled residents whose records were reviewed.

Inspectors wroteBased on interview, observations, and record review, the facility failed to ensure residents unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for 2 (#1 and #27) out of 32 sampled residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (#86, #37) out of 32 sampled residents as evidenced by failing to ensure: 1. staff removed PPE (Personal Protective Equipment) prior to exiting a resident's room that was on enhanced barrier precautions for Resident #86; and 2. failing to maintain a resident's urinary catheter in a sanitary manner for Resident #37.

Inspectors wroteBased on interviews and record reviews, S4CNA (Certified Nursing Assistant) failed to utilize and implement effective approaches of care for a resident with dementia to assure resident safety as evidenced by the CNA failing to call for assistance when the resident (#1) became combative while providing care, resulting in the resident sustaining injuries to his face and left arm for 1 (#1) out of 3 (#1, #2, and #3) sampled residents.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to develop and implement a person-centered care plan for 5 (#24, #47, #48, #53, and #91) out of 5 investigated for care plans out of a total sample of 37 residents by: 1. Failing to follow physician's orders for applying knee high compression stockings for Resident #24. 2. Failing to follow care plan by not monitoring edema for Resident #47. 3. Failing to develop a care plan for elevating lowering extremities and failing to implement a care plan for applying compression stockings for Resident #48. 4. Failing to develop a care plan to include interventions for the use of Regular Insulin for Resident #53. 5. Failing to develop the care plan to include interventions for the diagnosis of Dementia for the resident #91.

Inspectors wroteBased on record review and interview, the facility failed to ensure that a MDS (Minimum Data Set) assessment was completed and submitted to CMS (Center of Medicare And Medicaid Services) in a timely manner for 3 (#17, #24, #59) out of a final sample of 37 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to accurately assess 1 (#76) of 37 sampled residents' oral status. This had the potential to affect the 104 residents that reside in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure all required members of the IDT (Interdisciplinary Team) attended the care plan meeting for 1 (#60) out of 37 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory equipment was properly stored when not in use for 1(#23) out of 2 (#23 and #24) sampled residents reviewed for respiratory care out of a total sample of 37 residents.

Inspectors wroteBased on record review and interview, the facility failed to coordinate care as evidenced by failing to obtain pertinent information from the hospice agency for 1 (#19) out of 1 resident investigated for hospice and end of life care out of a total sample of 37 residents.

Inspectors wroteBased on observation, record review and interviews, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections as evidenced by staff failing to appropriately change gloves and sanitize hands during perineal care for 1 (#43) resident out of a total sample of 37 residents.

Inspectors wroteBased on record review and interviews the facility failed to notify the physician of a change in condition for 2 (#1, #2) of 3 (#1, #2, #3) sampled residents.

Inspectors wroteBased on record review, and interview, the facility failed to ensure that a physician or nurse practitioner provided orders for the resident's immediate care and needs for 1 (#1) of 3 (#1, #2, #3) sampled residents.