On With Life Long Term Care

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF812Dec 12, 2024

  Kitchen Based on observations, staff interview, and policy review the facility failed to serve food under sanitary conditions to prevent foodborne illness during one of two meals observed. Facility staff also failed to conceal hair completely in a hairnet to prevent foodborne illness. The facility reported a census of 40 residents. Findings include: Observations revealed the following: a. On 12/9/24 at 9:30 AM, the dietary supervisor wore a hairnet covering the hair pulled into a hair tie on the top of her head, but had the front, sides and back of the hair exposed (not in the hairnet). b. On 12/10/24 at 4:49 PM, Staff B, dietary aide, wore gloves while she served food to the residents. […]

• No harm, potential for more than minimal, patternF880Oct 7, 2021

  Based on observations, staff interviews, and facility policy review, the facility failed to follow accepted infection control practices during a COVID-19 outbreak. Staff failed to: sanitize a hoyer left after using it, two staff members failed to wear gloves while assisting two residents with activities of daily living (ADLS - one of the two staff members had long, artificial nails), and two staff members failed to wear the appropriate Personal Protective Equipment (PPE) while in the room of two residents with COVID-19. The facility reported a census of 31 residents. Findings include: On 9/16/21 at 9:25 AM during the entrance conference, the Administrator stated they had eight residents and six staff members that tested positive for COVID-19. […]

• No harm, potential for more than minimal, isolatedF755Aug 5, 2025

  Based on observations, record review, staff interviews, and facility policy review the facility failed to ensure accurate control, accountability, and disposition of scheduled controlled narcotic medication with narcotic medication not disposed of when the resident discharged from the facility for 1(Resident #1) of 1 resident reviewed and narcotic counts not being completed accurately. The facility reported a census of 38 residents. Findings include: The admission Minimum Data Set (MDS) for Resident #1, dated 5/15/25, documented diagnoses of stroke and hemiplegia (paralysis of one side of the body) with the resident dependent on staff for all activities of daily living. The MDS documented a Brief Interview of Mental Status was unable to be performed due to resident rarely/never understood. […]

• No harm, potential for more than minimal, isolatedF880Dec 12, 2024

  Based on observation, clinical record review, staff interview, and policy review, the facility failed to maintain infection control standards due to a catheter bag not maintained in a bag cover and lying on the floor under the resident's wheelchair for 1 (Resident #26) of 1 resident reviewed for catheter care. The facility reported a census of 40 residents. Findings include: The Quarterly Minimum Data Set (MDS) for Resident #26, dated 9/12/24, included diagnoses of anoxic (very low oxygen level) brain damage and seizure disorder. The Care Plan for Resident#26 with revision date 12/02/24 documented as focus area as follows; the resident had an indwelling urinary catheter due to urinary retention related to brain injury. […]

• No harm, potential for more than minimal, isolatedF641Sep 28, 2023

  Based on clinical record review, staff interview, guidance from the Resident Assessment Instrument (RAI) and the Centers for Disease Control (CDC) guidelines, and facility policy review the facility failed to accurately reflect the pneumococcal vaccination status on the Minimum Data Set (MDS) Assessment for 1 of 5 residents reviewed (Res #8). The facility reported a census of 31 residents. Findings include: The MDS for Resident #8 dated 9/4/23 identified a Brief Interview of Mental Status (BIMS) score of 4 out of 15 indicating severe cognitive impairment. The MDS documented diagnoses that included traumatic brain dysfunction and diabetes mellitus. The MDS reflected an admission to the facility date as 7/2/07 and a birth year of 1952. […]