SMP Health - Ave Maria

In the surveyor’s words

From the most serious findings on record at SMP Health - Ave Maria, in the surveyor’s own words.

• Immediate jeopardy, patternF880Aug 5, 2021

  F880 IS A REPEAT DEFICIENCY FROM THE SURVEYS COMPLETED ON 11/14/19 and 10/21/20. 1. Based on observation, review of facility policy, review of manufacturer's directions, review of professional reference, and staff interview, the facility failed to ensure staff followed standard infection control practices for 1 of 1 resident (Resident #1) observed receiving a blood glucose test with a shared blood glucose meter and has the potential to affect other residents in the facility. Failure to clean and disinfect shared glucose meters with the appropriate disinfectant has the potential to cause cross-contamination and may result in the transmission of blood-borne pathogens to other residents. […]

• Actual harm, isolatedF600May 20, 2026

  Based on record review, review of facility policy, review of the facility reported incident (FRI), and resident/staff interview, the facility failed to protect 2 of 2 sampled resident's (Resident #6 and #7) right to be free from physical abuse from each other. Failure to ensure residents remained free from physical abuse resulted in a physical altercation involving hair pulling, hitting, and biting which necessitated bloodborne pathogen testing. Findings include: The surveyor determined a deficient practice existed on 04/20/26. The facility implemented and completed corrective actions on 04/22/26. Review of the facility policy titled Abuse occurred on 05/20/26. This policy, revised January 2026, stated, Abuse is defined as a willful infliction of injury . intimidation . […]

• Actual harm, isolatedF600Jun 13, 2024

  Based on record review, review of facility policy, review of the facility's investigation reports, and staff interviews, the facility failed to ensure residents have the right to remain free from mental and/or physical abuse for 1 of 1 sampled resident (Resident #2) who had a rag placed in her mouth by staff to silence her. Failure to provide the services necessary to avoid mental anguish and emotional distress, resulted in an unsafe environment for Resident #2 and may result in fear, anxiety, and/or psychosocial harm. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately after hearing the concerns reported by staff. Findings include: Review of the facility policy titled Abuse occurred on 06/11/24. […]

• Actual harm, isolatedF689Aug 5, 2021

  Based on record review, review of the facility's investigative report, and staff interview, the facility failed to provide appropriate and sufficient supervision to prevent accidents for 1 of 1 sampled resident (Resident #88) who fell during a full body mechanical lift transfer and sustained a serious injury. Failure to safely utilize a mechanical lift resulted in Resident #88 falling from the lift and sustaining a serious injury, and placed all residents requiring this type of transfer at risk for falls and/or injury. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: Review of Resident #88's medical record occurred on August 2-5, 2021. […]

• No harm, potential for more than minimal, patternF880Sep 11, 2024

  Based on observation, record review, facility policy review, and staff interview, the facility failed to follow standards of infection control for 2 of 9 sampled residents (Resident #3 and #25) and 2 supplemental residents (Resident #50 and #70) observed during cares/dressing change and glucose monitoring. Failure to follow infection control practices during resident cares related to hand hygiene, enhanced barrier precautions (EBP), and cleaning of a glucometer has the potential to spread infection throughout the facility. Findings include: HAND HYGIENE Review of the facility policy titled Hand Hygiene occurred on 09/11/24. This policy, revised July 2024, stated, . Hand Hygiene Should Be Practiced: . […]