Mary Health of the Sick Convalescent & Nursing Hos

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. A frozen concentrated orange drink was found opened, spilled in its tray, undated, and expired inside the kitchen's walk-in refrigerator.2. Food crumbs, dirt, and trash were found on the floor beneath the dishwasher, compartment sink, and walk-in refrigerator areas.3. The Cook's mustache was not covered with a beard net. These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) in a vulnerable population of 49 residents who received food from the kitchen.Findings:During an initial observation tour of the kitchen and an interview with the Director of Food and Nutrition Services (DFNS), on 06/08/2026, at 8:02 AM, a frozen concentrated orange drink was found opened, spilled in its tray, undated, and expired inside the walk-in freezer. The DFNS stated he did not see the item when he checked the freezer.During an interview and record review with the DFNS on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure proper disposal of garbage when one of two trash receptacles had trash, and the lid was not closed.This failure had the potential to attract pests and rodents which could cause food borne illness for 49 medically compromised residents.Findings:During a facility tour and observation of the trash receptacle storage area outside the facility and interview with the Director of Maintenance (DM) on 06/08/2026, at 9:11 AM, one of two trash receptacles was observed to be open, and the trash was overflowing from the trash receptacle. The DM stated garbage was collected daily, except Sundays. The DM stated the staff who disposed of trash were responsible for ensuring the trash receptacle lids remained closed and that trash receptacles do not overflow. The DM further stated that unit supervisors should instruct staff not to overfill the trash receptacles and to ensure that trash was disposed of properly during weekends.During a concurrent interview with the DM on 06/10/2026 at 2:45 PM, the DM stated the trash…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure three of five sampled residents (Residents 4, 8, and 15) were free from unnecessary psychotropic medications (medications affecting brain activities associated with mental processes and behaviors) specifically lorazepam (generic for Ativan, a psychotropic medication to treat anxiety [feeling of fear, dread, or unease when stressed or anticipating a problem]) when:Resident 4 received seventeen doses of as needed lorazepam when Resident 4's assessed condition did not meet the clinical indication (the medical reason for a specific treatment, condition, or procedure) of the medication;Resident 8 received two doses of as needed lorazepam without documented justification for the medication administration; andResident 15 received six doses of as needed lorazepam with no behavior monitoring in place.These failures had the potential for the residents to inappropriately receive as needed psychotropic medications and had a risk of inaccurate clinical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an accurate assessment for one of four sampled residents (Resident 16) was completed when the Minimum Data Set ([MDS] - a federally mandated standardized assessment tool) assessment did not reflect the same hearing assessment conducted by the physician.This had the potential for unmet hearing services and appropriate interventions that may be necessary for Resident 16's care.Findings:During a concurrent observation and interview on 6/8/26 at 12:24 AM with Resident 16 at the facility dining area, Resident 16 was having difficulty hearing questions for an interview. Some questions had to be repeated several times before Resident 16 responded with an answer.During a review of Residents 16's admission Record, (a document showing a summary of the resident's information) dated 6/10/26, the admission Record indicated Resident 16 was admitted on [DATE].During a concurrent interview and record review on 6/9/26 at 4:40 PM with the MDS Coordinator (MDSC),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement interventions according to the care plans for two of five sampled residents (Residents 1 and 16) when:1. Resident 1's oxygen saturation ([O2 sat] - a measurement of how much oxygen the blood is carrying as a percentage) was not checked every shift (the period of a scheduled time of the day a nurse/nurses work), as indicated in the care plan. This failure had the potential for Resident 1's oxygen saturation to go unnoticed even when not within normal limits.2. Resident 16 had edema (swelling from a buildup of extra fluid) on both lower legs and they were not elevated with pillows as indicated in the care plan. This failure had the potential to prevent improved blood flow in the legs that could reduce swelling from fluid buildup.Findings:1. During a review of Resident 1's admission Record, (a document showing a summary of the resident's information) dated 6/11/26, the admission Record indicated Resident 1 was admitted on [DATE], with diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility document and policy review, the facility failed to ensure foods were stored in accordance with professional standards for food safety. Specifically, the facility failed to ensure warm milk placed into the refrigerator to cool was loosely covered to facilitate heat transfer; failed to ensure food items, including frozen carrots and frozen fish, were stored in closed containers and protected from exposure to the air; and failed to ensure a utensil storage rack was free of an accumulation of dust and debris. These failures had the potential to affect all residents receiving meals from the dietary department. Findings included: 1. A facility policy titled, Cooling and Reheating of Potentially Hazardous or Time/Temperature Control for Safety Food, dated 2023, indicated, Cooked Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) food shall be cooled and reheated in a method to ensure food safety. The policy specified, When PHF or TCS food will not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to maintain a sanitary kitchen and store food in accordance with professional standards for food service safety when: 1. There were several black residue build-up on the floor in the dishwashing area. 2. Food items in the dry storage room had no received date labels and were beyond the best if used by date. 3. Food items in the dry storage room had no received date labels. These failures had the potential to contaminate residents' food and cause foodborne (illness caused by food contaminated with bacteria and viruses) illnesses to a population of 45 medically compromised residents who received food from the kitchen. Findings: 1. During an initial kitchen tour observation on February 6, 2023, at 8:51 AM, in the dish washing area, there were several black residue build-up on the floor under the dishwashing machine. During an observation of the dishwashing area and concurrent interview on February 6, 2023, at 10:03 AM, with the Director of Food and Nutrition Services (DFNS), the DFNS acknowledged the finding and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to create a facility assessment specific to the needs of the facility's population and location as part of the required facility assessment, when the facility assessment did not include the required water management program. This deficient practice failed to establish an individualized facility assessment to meet the requirement for a water management program which had the potential to place the residents at risk for outbreak of an opportunistic waterborne (a disease or infection that people can catch from infected water) pathogen causing disease. Findings: During an interview and concurrent record review of the Facility Assessment with the Administrator on February 7, 2023, at 3:08 PM, the Facility Assessment did address a water management program. The Administrator stated the facility did not have a water management program in place to prevent the development and transmission of Legionnaires' disease (a severe, often lethal, form of pneumonia [lung inflammation caused by bacterial, in which the lung air sacs fill with pus],…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to have measures in place to prevent the growth of Legionella (a bacteria that can be found in water systems such as air conditioners, showers, sinks, and water fountains) and other opportunistic waterborne (a disease or infection that people can catch from infected water) pathogens in building water systems. This failure resulted in the facility not having a water management program which potentially exposed the residents of the facility to Legionella and other harmful waterborne pathogens. Findings: During an interview and concurrent record review with the Administrator on February 7, 2023, at 3:08 p.m., the Facility Assessment did not address a water management program. The Administrator stated they did not conduct water testing to ensure Legionella and other harmful waterborne pathogens were not present in the facility's water system. The Administrator further stated the facility did not have a water management program in place to prevent the development and transmission of Legionnaires' disease (a severe, often lethal,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure care plan was updated and revised for one of 15 residents (Resident 37) reviewed for care plans when Resident 37's care plan for self-care deficit was not revised in a timely manner. This failure did not reflect Resident 37's current care status which had the potential to result in inconsistent care coordination and unmet care needs for Resident 37. Findings: During an observation with Resident 37, on February 6, 2023, at 11:20 AM, inside the room, Resident 37 was lying in bed, with a splint (an appliance used for supporting and protecting tissues) on the right arm and holding a rolled towel on the left hand. Resident 37 was awake, non-verbal, calm, and did not appear to be in any acute distress. A review of Resident 37's clinical record, the admission Record (contains demographic and medical information) indicated Resident 37 was admitted to the facility on [DATE], with diagnoses that included hemiplegia/hemiparesis (brain injury…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to flush the gastrostomy tube (g-tube - a tube inserted through the wall of the abdomen directly into the stomach that can be used to give food and medication to a person) before medication administration for one of one resident (Resident 21) with g-tube during medication administration observation. This deficient practice resulted in a clogged g-tube for Resident 21 during medication administration, and had the potential to delay and compromise Resident 21's nutritional needs. Findings: During an observation and concurrent interview with Licensed Vocation Nurse 1 (LVN 1), on February 8, 2023, at 8:28 AM, in the room, LVN 1 was observed administering medications for Resident 21 through g-tube by gravity. LVN 1 did not flush the g-tube with water before administering the medications. Resident 21's medications were not flowing down, and the g-tube was observed to be clogged while LVN 1 was giving the medications. LVN 1 stated Resident 21 did…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure accurate accounting of two controlled substances (medications which are used and distributed with control because of the potential for abuse) for two residents (Residents 2 and 37) in one of two sampled medication carts (Station 1 Medication Cart A). This deficient practice had the potential for loss of accountability and increased the risk that medications may not be available for Residents 2 and 37, when needed, and increased the facility's risk for potential loss, diversion (transfer of a medication from legal to an illegal use), or accidental exposure to controlled substances. Findings: During an observation of Station 1 Medication Cart A, with Licensed Vocational Nurse 2 (LVN 2), on February 8, 2023, at 1:31 PM, the following discrepancies were found between the Controlled Drug Record (a log signed by the nurse with date, time, and amount of medication each time a controlled substance is given to a resident) and the medication container: 1. Resident 2's Controlled Drug Record for Morphine Sulfate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 347) was free from significant medication error when Resident 347's controlled medication (medication used and distributed with control because of the potential for abuse) was not administered according to physician's order. This deficient practice had the potential for Resident 347 not to receive the scheduled medication which could lead to the resident's decline in health, hospitalization, or death. Findings: During medication administration observation with Licensed Vocational Nurse 2 (LVN 2), on February 8, 2023, at 7:56 AM, in Station 1 hallway, LVN 2 was observed preparing medications, and administered all prepared medications to Resident 347. During an interview and concurrent record review with LVN 2, on February 8, 2023, at 8:17 AM, the Electronic Medication Administration Record for Resident 347 indicated an order of Lacosamide (medication used to treat seizures [uncontrolled body…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to discard two expired over the counter medications in two out of two sampled medication carts. This deficient practice had the potential for loss of strength of the medication and for the residents to receive ineffective medication. Findings: 1. During an observation and concurrent interview with Licensed Vocational Nurse 1 (LVN 1), on February 8, 2023, at 10:31 AM, in Station 2 Medication Cart A, one bottle of Activated Charcoal (indicated for preliminary elimination of the toxin in moderate to severe cases of poisoning) 780 mg (milligram - unit of measure that equals to one of a thousandth gram) was found for Resident 4 with an expiration date of 01/2023. LVN 1 verified the medication was expired and stated expired medications should be discarded to prevent from giving it to the resident. During an interview with the Director of Nursing (DON), on February 8, 2023, at 11:27 AM, the DON stated that any expired medications should be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.