St. Barbara's Memorial Nursing Home

Inspectors wroteBased on observation and staff interviews, the facility failed to dispose of garbage and refuse properly. This failed practice had the potential to affect all residents in the facility. Facility census: 48Findings Included:a) Observation and staff interview:On 08/12/25 at 2:45PM, during an observation walk around interview with Maintenance employee # 60 who acknowledged Dumpster #2 was observed to be heavily rusted and leaking around the bottom and the right side lid was hooved up and not [NAME] closing. He stated he would call the waste company and request a replacement dumpster to be sent out.

Inspectors wroteBased on staff and resident interviews, and observation The Facility failed to ensure residents rights to file grievances anonymously. This deficient practice had the potential to affect more than a limited number of residents. Facility census:

Inspectors wrote761 Based on staff Interviews and Record review the facility failed to keep an accurate record of the medication rooms refrigerator temperature logs. This failed practice was a random opportunity for discovery, and had the potential to affect all residents residing in the long term care facility that require temperature controlled medications. Resident Identifier: All residents with medications in refrigerator Facility Census: 48The facility FAILED TO MEET THE STANDARD OF PRACTICE as evidenced by the following

Inspectors wroteBased on observation, interview and policy review the facility failed to properly store food in accordance with professional standards. This is true for the facility kitchen Coolers and also 2 staff members not wearing proper hair covering during lunch meal prep. This had the potential to affect all residents in the facility. Facility census: 48Findings included:On 08/11/25 at 11:49 AM, during Initial Brief Tour of Kitchen, with The Dietary Manager #52 who acknowledged the following: 2 staff members without proper hair covering while preparing resident's lunch, apple juice in 2 door cooler without an opening date and multiple garden salads with no date labels in the 3 door cooler. Policy and Procedures:On 08/13/25 at 1:00 PM a review Food Safety Policy, Food Storage: labeled C. Refrigerated Foods. Practices to maintain safe refrigerated storage, number's 3. C, iv. [...]

Inspectors wrote637 Based on staff Interviews and Record review the facility failed to maintain proper MDS documentation after a significant change in condition (CIC), specifically a wound to the Right Heel of resident #4. This failed practice was a random opportunity for discovery and effected 1:16 residents sampled in the facility. Resident Identifier: #4 Facility Census: 48The Facility FAILED TO MEET THE STANDARD PRACTICE, as evidenced by the following

Inspectors wroteBased on record review and staff interview, the facility failed to update the Resident Pre-admission Screening(PASARR) after admission to the facility, resident #2 was diagnosed with a major mental disorder. This was true for one (1) of six (6) residents reviewed for PASARRs during the survey process. Resident Identifier #2 Facility census: 48. Findings Included:Resident #2 Record Review:On 08/12/2024, a review of Resident #2's medical record was performed including diagnoses and Resident's Pre-admission Screening (PASARR). His last updated PASARR was completed on 07/262024. Resident #2 was noted to have received a diagnosis of Psychotic Disorder on 05/28/25. An updated PASARR has not been completed since 07/26/2024. [...]

Inspectors wroteBased on record review, and interview, the facility failed to update the resident's Preadmission Screening and Resident Review (PASARR) with a new diagnosis of mental illness. This was true for one (1) of four (4) residents sampled. Resident Identifier #15. Facility Census: 58. Findings Include Resident #1508/11/2025 10:22 PM PASSAR 07/25/16No MI documented Record review on 07/11/25 at approximately 2:52 PM revealed that the most recent PASSAR for Resident #15 was dated 07/25/16. The PASSAR noted that there were no mental illness or mental retardation (MI/MR) diagnoses for the resident. Ongoing record review on 07/11/25 at 3:06 PM revealed that the resident was diagnosed with the following on 07/01/25: [...]

Inspectors wrote684 Based on staff Interviews and Record review the facility failed to maintain proper MDS documentation ensuring the quality of care was maintained. This failed practice was a random opportunity for discovery and effected 1:16 residents sampled in the facility. Resident Identifier: #4 Facility Census: 48The Facility FAILED TO MEET THE STANDARD PRACTICE, as evidenced by the following

Inspectors wroteBased on medical record review, staff interview, and operation policy, the facility failed to take actions to thoroughly investigate an alleged violation related to physical abuse. Resident identifier #1. Facility census: 52.

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to ensure an environment was free from accident hazards over which the facility had control to prevent avoidable accidents. The medication cart was left unlocked on the Old Wing hallway and items were stored improperly on the shelves above resident beds. Room identifiers: 29, 26, 27, 14, 12, 9, 30, 22, 10, and 18. Facility census: 49.

Inspectors wroteBased on observations and staff interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The ice machine had been improperly installed, with the drain line in direct contact with the floor drain. There was no gap between the drip line and floor drain to prevent backflow from siphonage or back pressure. Additionally, the facility failed to pass ice in a safe and sanitary manner. The ice scoop was improperly stored during the hydration pass. Facility census: 49.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain an effective infection control program. Staff touched medications with bare hands, failed to follow enhanced barrier precautions during care and failed to provide incontinence care in a safe and sanitary manner. In addition, hand hygiene was not performed by staff between residents during assistance with meals. These deficiencies were random opportunities for discovery and have the potential to affect more than a limited number of residents. Resident identifiers: #30 #49, #5, and #41. Facility census: 49.

Inspectors wroteBased on record review and staff interview, the facility failed to complete a new Pre-admission Screening (PAS) for one (1) of one (1) residents reviewed for the category of PASARR (Pre-admission Screening and Resident Review), during the long-term care survey process. Resident identifier #29. Facility census 49.

Inspectors wroteBased on observation, staff interview, policy and procedure review, the facility failed to ensure a resident who was experiencing an acute episode of pain was provided appropriate interventions to assist with pain management. Resident identifier: #5. Facility census: 49.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure complete and accurate medical records. A Physician Orders for Scope of Treatment (POST) form was incomplete for one (1) of 16 records reviewed for accurate POST forms. Resident identifier: #29. Facility census: 49.

Inspectors wroteBased on medical record review and staff interview, the facility failed to collaborate with hospice services to develop a coordinated person-centered care plan for one (1) of one (1) residents reviewed for the area of hospice. The care plan for Resident #10 did not specify when and what specific services were to be provided by the hospice staff. Resident identifier: #10. Facility census: 49.

Inspectors wroteBased on observation, resident interview, and staff interview the facility failed to offer appealing options of similar nutritive value to residents who chose not to eat food that was initially served or who requested a different meal choice. This practice had the potential to effect every resident receiving nutrition from the kitchen. Resident identifier: #35. Facility census: 48. Findings Inluded: a) resident #35 11/28/22 11:40 PM Staff interviewed resident #35 who states she did not like lunch meal and asked for alternative meal. Told only had soup and peanut butter and jelly sandwiches. She had a peanut butter and jelly sandwich. Stated food quality has gone downhill since January 2022. Must be cutting costs. She states she likes the chef and he tries his best. On 11/29/22 at 10:07 AM, staff interviewed Dietary Manager (DM) #5 concerning alternative meal menu. [...]

Inspectors wroteBased on resident interviews, resident representative interviews, review of the Payroll-Based Journal (PBJ) Staffing Data Report, review of Center for Medicare and Medicaid Services (CMS) Nursing Home Compare's report for the facility, and staff interview, the facility failed to ensure sufficient qualified nursing staff were available on weekends to provide nursing and related services to meet the residents' needs safely and in a manner that promoted resident rights, physical, mental and psychosocial well-being. The low weekend staffing had the potential to affect more than a limited number of residents in the facility. Facility census: 48.

Inspectors wroteBased on staff observation, the facility failed to assure that food was stored and prepared in accordance with professional standards for food service safety as evidenced by the downstairs freezer temperatures not being monitored on a daily basis and additionally, the ceiling in the kitchen was perforated potentially allowing dust and other particles to contaminate food. The lack of temperture checks and the perforated kitchen ceiling had the potential to affect more than a limited number of residents in the building. Facility census:

Inspectors wroteBased on record review and staff interview, the facility failed to provide the required Notification of Medicare Non-Coverage (NOMNC) liability notice in a timely fashion for one (1) of three (3) residents reviewed for beneficiary protection notification and failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) Form CMS-10055 for one (1) of three (3) residents. This failure placed residents at risk of not being informed of their appeal rights prior to the end of Medicare covered services. Resident identifiers: #21 and #41. Facility census: 48.

Inspectors wroteBased on observation, family interview, record review, and staff interview, the facility failed to provide the necessary services to maintain grooming and personal hygiene for residents who were unable to independently carry out activities of daily living (ADL). This was true for two (2) of 16 residents reviewed for ADL's. Resident identifiers: #39 and #152. Facility census: 48.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the attending physician documented the rationale for no action taken when reviewing monthly Medication Regimen Review (MMR) recommendations from the licensed pharmacist. This was true for one (1) of five (5) residents reviewed under the unnecessary medication pathway. Resident identifier #24. Facility census: 48.