Our Lady of Peace Inc

In the surveyor’s words

From the most serious findings on record at Our Lady of Peace Inc, in the surveyor’s own words.

• Actual harm, isolatedF686Jan 12, 2023

  Based on observation, clinical record review, staff interview, and facility document review, the facility staff failed to provide treatment and services for the prevention of an unstageable pressure ulcers for one of 13 residents, Resident #23. This was identified as harm. The facility also failed to accurately complete weekly skin observations for one of thirteen residents, Resident #15. Findings were: 1. Resident #23 was admitted to the facility with the following diagnoses, including but not limited to: Dementia with agitation, depressive disorder, anxiety, and psoriasis. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 11/01/2022. […]

• Actual harm, isolatedF692Jan 12, 2023

  Based on observation, staff interview, and clinical record review, the facility staff failed to implement interventions for a significant weight loss for one of 13 residents, Resident #23. During a six month time span from 06/09/2022 until 12/07/2022, Resident #23 lost 21.50% (23 pounds). Resident #23 was not assessed by the registered dietician at the facility, nor were any interventions put in place to address her significant weight loss. This was identified as harm by the survey team. Findings were: Resident #23 was admitted to the facility with the following diagnoses, including but not limited to: Dementia with agitation, depressive disorder, anxiety, and psoriasis. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 11/01/2022. […]

• No harm, potential for more than minimal, widespreadF814Mar 19, 2026

  Based on observation, staff interview, and facility document review, the facility staff failed to properly dispose of trash in one of one facility dumpster.The findings include:On 3/17/26 at 11:09 a.m., the Director of Maintenance and the Director of Dining Services accompanied the surveyor outside the building for observation of the dumpster. The dumpster did not have a cover over it. The Director of Dining Services attempted to close the two piece lid to the dumpster. The two pieces did not cover the entire top to the dumpster; multiple areas remained open to air even after the lid pieces were pulled over the top. The Director of Maintenance stated the dumpster is emptied every day and had not been closed since it had been emptied earlier in the morning. […]

• No harm, potential for more than minimal, patternF656Mar 19, 2026

  Based on observation, clinical record review, staff interview and facility document review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for five of 19 residents in the survey sample, Residents #9, #6, #18, #17 and #8. The findings include:1. For Resident #9 (R9), the facility staff failed to develop the comprehensive care plan to address nutritional needs and weight loss. R9 was admitted to the facility with diagnoses that included but were not limited to protein-calorie malnutrition (1), dementia (2) and bariatric surgery status (3). […]

• No harm, potential for more than minimal, patternF679Mar 19, 2026

  Based on observations, staff interview, and facility document review, the facility staff failed to provide person-centered activities based on the comprehensive assessment and resident preferences for one of 19 residents in the survey sample, Resident #18.The findings include:For Resident #18 (R18) the facility staff failed to provide meaningful, person centered activities based on his preferences and holistic needs in February and March 2026.During the course of the survey, the following observations were made:On 3/17/26 at 11:40 a.m., R18 was seated in a wheelchair in the middle of the hallway. He was leaning forward in his wheelchair grasping at his right ankle. […]