St. Marks Living

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure dishwashing sanitization temperatures for 1 of 1 dishwashers had been appropriately monitored to prevent the risk of foodborne illness. This had the potential to effect all 30 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure ongoing surveillance for infections, ongoing review of surveillance data, and documentation of follow-up activity and response. This practice had the potential to affect all 30 residents residing in the facility. In addition, based on observation and interview, the facility failed to ensure a glucometer (a small portable device used to measure the amount of glucose in a drop of blood) used on multiple residents, had been disinfected after use on 1 of 1 resident (R17), revewed for infection control practices.

Inspectors wroteBased on interview and document review, the facility failed to implement a process for antibiotic review to determine appropriate indications, dosage, duration, trends of antibiotic use and resistance. This had the potential to affect all 30 residents residing in the facility.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment for residents residing in Golden Oak Hall resulting in numerous large, dark stains throughout the hallway carpeting. This had the potential to affect all 20 residents who resided on the Golden Oak Hall. In addition, the facility failed to repair gaps in an exterior service door allowing the potential for rodents to enter the building. This had the potential to affect all 30 residents who resided in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure accuracy of the Minimum Data Set (MDS) assessment for 1 of 5 residents (R6), reviewed for unnecessary medications, when the MDS did not reflect opioid (a narcotic pain medication) and diuretic (increases urine production) medications R6 had been receiving.

Inspectors wroteBased on observation, interview, and document review, the facility failed to follow physician orders during a dressing change and failed to assess and document the condition of finger wound during weekly skin assessments for a non-pressure skin condition for 1 of 2 residents (R1) reviewed for non-pressure skin In addition, based on interview and document review, the facility failed to ensure physician orders were carried out for 1 of 1 residents (R3) reviewed for unnecessary medications, when a physician was not informed of elevated blood sugar levels.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure safe transfers with a sit-to-stand mechanical lift and/or total body mechanical lift for 2 of 3 residents (R4 and R9) reviewed for falls/safety. The facility's failure resulted in immediate jeopardy (IJ) for R4 when staff were observed to use the wrong size harness for sit-to-stand mechanical lift transfer after a previous fall from sit-to-stand lift on 12/21/25 which resulted in minor injuries. In addition, the facility failed to comprehensively investigate/analyze falls for root cause, implement appropriate interventions to prevent and/or reduce the risk for future falls for 1 of 3 residents (R3) reviewed for falls/safety. [...]

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure residents at risk for or with pressure ulcers received ongoing comprehensive assessment, individualized reassessment of pressure-relief effectiveness, and revised interventions necessary to prevent deterioration and support healing for 3 of 3 residents (R10, R4, R9) reviewed for pressure ulcers. This resulted in actual harm for R10 who had facility acquired stage 2 pressure ulcer on left sacral region (buttock) that deteriorated to a stage 3 pressure ulcer.

Inspectors wroteBased on interviews and document review the facility failed to ensure that 1 of 1 resident (R1) was free of a significant medication error by not observing the rights of medication administration. This caused actual harm for R1 when she was administered another resident's medications became unresponsive and had to be hospitalized for hypotension and acute kidney injury. In addition, based on observation and interview the facility failed to ensure appropriate correction measures after R1's medication errors to decrease the risk or reduce the risk of significant medication errors and could have prevented or reduced the risk additional medication errors that were not significant for 2 of 2 residents (R12, R5) observed during medication pass.

Inspectors wroteBased on interview and document review the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee identified, investigated, analyzed, and responded high risk issues related to a falls, medication errors, and pressure ulcers by developing and implementing action plans for process improvement. This deficient practice had the potential to affect all 36 residents that resident in the facility.

Inspectors wroteBased on interview and document review, the facility failed to notify a physician for a change of condition for 1 of 3 residents (R3) who had a syncopal episode.

Inspectors wroteBased on interviews and document review the facility failed to maintain a complete, accurate and readily accessible medical record was maintained for 1 of 1 (R1) resident reviewed for significant medication error.

Inspectors wroteBased on observation, interview and document review, the facility failed to monitor the concentration of sanitizer used in the 3-compartment sink to ensure proper sanitation for cleaning pots and pans. This had the potential to affect all 36 residents who were served food from the kitchen.

Inspectors wroteBased on interview and document review, the facility failed to submit accurate and/or complete data for staffing information, based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed (Quarter 1, 2024), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS.This deficient practice had the potential to affect all 36 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to implement a process for antibiotic review in order to determine appropriate indications, dosage, duration, trends of antibiotic use and resistance. This had the potential to affect any residents who had infections requiring antibiotic use.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure a comprehensive care plan was developed to include of post-traumatic stress disorder (PTSD) triggers and interventions for 1 of 1 resident (R25) who had a diagnosis of PTSD. R25's admission Minimum Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition, feeling down, depressed or hopeless nearly every day, dependent on staff for personal hygiene, dressing, toileting, utilized a walker and wheelchair, diagnoses included psychotic disorder and post-traumatic stress disorder (PTSD), and antipsychotics were received on a routine basis. R25's care plan dated 2/28/25, indicated medications daily for PTSD, psychosis, monitor/record occurrence of target behaviors: worried expression, verbalization of worries. monitor/record target behaviors: [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure physician orders were followed for pressure ulcer (PU) wound care for 1 of 1 resident (R2) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide services to maintain and prevent loss of range of motion (ROM) for 1 of 2 residents (R7) reviewed for limited ROM.

Inspectors wroteBased on observation, interview and document review the facility failed to assess and follow provider orders for removal of an indwelling urinary catheter as soon as possible to restore urinary continence for 1 of 1 resident (R25) reviewed for catheter care.

Inspectors wroteBased on interview and document review, the facility failed to assess trauma history and identify potential triggers for 1 of 1 resident (R25) who had a diagnosis of post-traumatic stress disorder (PTSD).

Inspectors wroteBased on interview and document review, the facility failed to ensure 2 of 5 residents (R30, R34) reviewed for immunization status, had been provided education regarding the risks, benefits and potential side effects of the influenza and pneumococcal vaccines in accordance with facility policy and the Centers for Disease Control and Prevention (CDC) recommendations.

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess and monitor non-pressure related impairments in skin integrity for 3 of 3 (R1, R2, R3) residents reviewed for injuries. Addtionally the facility failed to ensure appropriate interventions were in place to reduce bruising for 1 of 1 resident (R1) at risk for bruising due to taking an anticoagulant (medication that prevents blood clots from forming)

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess and evaluate causal factors for a fall and develop and monitor the effectiveness of appropriate interventions to reduce the risk of falls for 3 of 3 residents (R2, R1, R3) reviewed. Additionally, the facility failed to implement identified interventions for 2 of 3 residents (R1, R3) reviewed.

Inspectors wroteBased on interview and document review, the facility failed to properly insert an indwelling urinary catheter and failed to assess and monitor for complications following insertion for 1 of 3 (R1) residents reviewed for catheters. This resulted in harm for R1 when the catheter balloon was improperly inflated in the urethra causing perforation within urethra, hospitalization for hematuria (blood in urine), and a urinary tract infection. The facility implemented immediate corrective action, so the deficient practice was issued at past non-compliance.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure enhanced barrier precautions (EBP-where gown and gloves used for high contact resident care activities) was used for 3 of 4 residents (R4, R2, R1) observed for EBP. In addition, the facility failed to ensure handwashing/hand hygiene was implemented for 3 of 5 residents (R4, R2, R5) observed for hand hygiene.

Inspectors wroteBased on observation, interviews and document review the facility failed to provide a dignified dining experience for 1 of 1 resident (R4) observed for dining.

Inspectors wroteBased on interviews and document review the facility failed to maintain a complete, accurate and readily accessible medical record was maintained for 1 of 1 (R1) residents reviewed for complete and accurate medical records.

Inspectors wroteBased on interview and document review, the facility failed to ensure resident (R19) and responsible party (FM-A) were notified of a room change for 1 of 1 resident (R19) reviewed for notification of change.

Inspectors wroteDuring interview and record review the facility failed to ensure a written notice of bed hold was provided for 2 of 2 residents (R19, R33) reviewed for hospitalizations.

Inspectors wroteBased on interview and document review the facility failed to ensure influenza vaccinations were offered to 1 of 5 residents (R4) reviewed for immunizations.