St Marks Living

In the surveyor’s words

From the most serious findings on record at St Marks Living, in the surveyor’s own words.

• Immediate jeopardy, patternF689Jan 10, 2022

  Based on observation, interview, and document review, the facility failed to complete comprehensive safe transfer assessments for 9 of 9 residents (R1, R2, R3, R4, R5, R6, R7, R8, and R9), ensure the appropriate sling size was used for safe transfer for 4 of 9 residents (R1, R6, R5, and R8), develop a consistent system for repair of mechanical lifts, and failed to assess staff competency to ensure safe transfers via full body mechanical lifts. The facility's failures resulted in actual falls with injury for 2 of 9 residents (R1, R6) and immediate jeopardy (IJ) situation for (R1). […]

• Immediate jeopardy, isolatedF689Mar 2, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF678Jul 20, 2022

  Based on interview and document review, the facility failed to follow the Provider Orders for Life Sustaining Treatment (POLST), did not initiate cardiopulmonary resuscitation (CPR) as per the residents wishes for CPR for 1 of 3 resident (R)7 resident reviewed for CPR status. R7 was found without a pulse or respirations and staff did not initiate CPR and R7 expired. This resulted in an Immediate Jeopardy (IJ) for R7. The IJ began on [DATE], at 4:40 a.m. when licensed practical nurse (LPN)-A failed to follow the POLST and did not initiate CPR as per R7's wishes. The administrator and director of nursing (DON) were notified of the IJ on [DATE], at 4:05 p.m. The facility implemented corrective action and the IJ was removed on [DATE], at 4:20 p.m. […]

• Actual harm, isolatedF686Mar 2, 2026

  Based 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. Findings include: Pressure Ulcer/Injury (PU/PI) is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. […]

• Actual harm, isolatedF760Mar 2, 2026

  Based 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. […]