On With Life

In the surveyor’s words

From the most serious findings on record at On With Life, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 11, 2026

  Based on clinical health record review, facility document review, staff interviews, and policy review, the facility failed to provide adequate supervision resulting in residents attempting to or exiting the building without staff knowledge for 2 of 3 residents reviewed for inadequate nursing supervision (Residents #1 and #2). The facility reported a census of 21. Findings include: 1. The Minimum Data Set (MDS) Assessment completed on 2/18/26 revealed Resident #1 with a Brief Interview for Mental Status score of 9, indicating a moderate cognitive impairment. The MDS further noted Resident #1 as inattentive with disorganized thinking that is continuously present without fluctuations. Diagnoses include attention and concentration deficit, traumatic brain injury, and quadriplegia. […]

• No harm, potential for more than minimal, patternF880Oct 10, 2024

  Based on observations, staff interviews, clinical record review, and policy review, the facility failed to follow enhanced barrier protection practices for residents with indwelling medical devices for 5 of 5 residents reviewed for infection control (Resident #3, #13, #16, #27, and #25). The facility reported a census of 25. Findings include: 1. The Minimal Data Set (MDS) assessment dated [DATE] revealed Resident #3 had diagnoses of traumatic spinal cord dysfunction, multidrug-resistant organism (MDRO), resistance to Vancomycin, paraplegia, and quadriplegia. The MDS assessment documented the presence of an indwelling catheter. The Care Plan dated 10/9/24 revealed Resident #3 had a suprapubic catheter related to his spinal cord injury. […]