Maries Manor

Inspectors wroteBased on interview and record review, facility staff failed to ensure one resident (Resident #1) remained free from accidents when Resident #1 received Resident #2's medications. The facility census was 66. 1. Review of the facility's Medications, Errors and Drug Reactions policy, undated, showed staff are directed to safeguard the resident and provide emergency care as needed. Complete a resident assessment every shift for at least seventy-two hours. The policy did not address contacting the pharmacy after a medication error. Review of the facility's Medication Administration Guidelines policy, undated, showed it is the purpose of this facility that residents receive their medications on a timely basis and accordance with established policies. [...]

Inspectors wroteBased on observation and interview, the facility staff failed to maintain the kitchen ceiling in good repair to prevent contamination of food items. This failure has the potential to affect all residents. The facility census was 65.1. Observation on 08/12/25 at 11:40 A.M. showed the kitchen with the following: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to appropriately sanitize a multi-use glucometer (a device for monitoring blood sugars) between use for two (Resident #3, and #51) out of five sampled residents. Staff failed to perform appropriate hand hygiene and glove changes in a manner to prevent or reduce the spread of bacteria and other infection causing organisms during blood glucose checks for three (Resident #28, #45, and #51) out of five sampled residents. Staff failed to utilize personal protective equipment (PPE) for two (Resident #7 and #47) out of two sampled residents on enhanced barrier precautions (EBP) during wound care and/or catheter care The facility census was 65.1. Review of the facility's policies showed staff did not provide a policy on glucometer disinfection. [...]

Inspectors wroteBased on interview and record review, facility staff failed to implement an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor and track antibiotic use within the facility. The facility census was 65. 1. Review of the facility's policy titled, Antibiotic Stewardship Program , dated 4/10/25, showed: -The Director of Nursing (DON) will be responsible to audit the clinical assessment documentation at the time of the antibiotic prescription. [...]

Inspectors wroteBased on interview, and record review, facility staff failed to maintain professional standards of practice when staff failed to transcribe a treatment order for one resident (Resident #7) and accurately transcribe a medication order for a Fentanyl patch (to treat pain) for one resident (Resident #75) out of two sampled. The facility census was 65.1. Review of the Facility's Wound Care Treatment policy, undated, showed there must be a specific order for the treatment. 2. Review of Resident #7's admission Minimum Data Set (MDS), a federally mandated assessment tool, 06/30/25, showed staff assessed the resident as:-Cognitively intact;-At risk for developing pressure ulcers/injuries;-Has a stage 1 unhealed pressure injury (initial stage of skin and tissue damage caused by prolonged pressure). [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to destroy medications weekly and failed to store the medication behind a lock cabinet for 27 residents (Resident #2, #10, #26, #29, #30, #31, #32, #37, #42, #46, #53, #56, #59, #65, #66, #67, #68, #76, #77, #80, #81, #82, #83, #84, #85, #86, and #87). The facility census was 65.1. Review of the facility's Storage of Medications policy, undated, showed the following guidelines: -All medications for residents must be stored at or near the nurse's station in a locked cabinet, a locked medicine room, or one or more locked mobile medication carts;-Medications must be stored in the container in which they were received;-Drugs must be stored in an orderly manner in cabinets, drawers, or carts. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to follow professional standards when staff prepared 40 medication cups with medications prior to the timed medication pass and performed resident blood sugar tests with expired test strips for four residents (Resident #14, #58, #61, and #62) out of four sampled residents. The facility census was 64. 1. Review of the facility's policy titled, Medication Administration Guidelines, dated 03/2015, showed facility staff are directed as follows: -The complete act of administration entails removing an individual dose from a previously dispensed, properly labels container, verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the information; -Medications may not be prepared in advance and must be administered within one hour of preparation; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to store and label medications in a safe and effective manner when staff failed to date the opened multi-dose medication bottles, insulin vials, and medications were left unattended on top of one medication cart. The facility census was 64. 1. Review of the facility's Storage of Medication policy, undated, shows facility staff were directed as follows: -All medications for residents must be stored at or near the nurse's station in a locked medicine room or one or more locked mobile medication carts; -All mobile medication carts must be under visual control of the staff at all times when not stored safely and securely; -No discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. [...]

Inspectors wroteBased on interview and record review, facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. This failure has the potential to affect all residents. The facility census was 64. 1. Review of the facility's Dining Services Supervision policy, dated May 2015, showed Overall supervisory responsibility of the Dining Services Department shall be assigned to a full-time qualified Dining Services Manager. This Dining Services Manager, if not qualified, functions with frequent regularly scheduled consultation from a person so qualified. Review showed the policy did not contain information related to the education and experience requirements for the dining services manager. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff to wear facial hair restraints to protect food and food contact surfaces from potential contamination. The facility staff failed to allow sanitized dishes to air dry prior to stacking in storage and use to prevent the growth of food-borne pathogens. These failures have the potential to affect all residents. The facility census was 64. 1. Review of the facility's Dietary Personnel Guidelines policy, dated May 2015, showed the policy directed hairnets or bouffant disposable caps should be worn at all times and should cover the entire head of hair. Review showed the policy did not contain information related to facial hair restraints. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure call lights were within reach for three residents (Resident #18, #44, and #51) out of 16 sampled residents. The facility census was 64. 1. Review of facility's Call Light, Use of policy, undated, showed the following: -Respond promptly to resident's call for assistance; -When providing care to residents, be sure to position the call light conveniently for the resident's use. -Be sure all call lights are placed on the bed at all times, never on the floor or bedside stand. -Check the call light system at regular intervals. 2. Review of Resident #18's Quarterly Minimum Data Set (MDS) a federally mandated assessment tool, dated 02/27/24, showed staff assessed the resident as: -Moderate cognitive impairment; -Diagnoses: Dementia, and Traumatic brain injury (TBI); [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to review and revise care plan for one resident (Resident #3) out of one sampled resident with interventions for cellulitis and for one resident (Resident #47) out of one sampled resident with medication noncompliance. The facility census was 64. 1. Review of the facility's policies showed staff did not provide a policy for care plans. 2. Review of the facility's Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, 3.0 and Care Planning Policy, undated, showed: -The Comprehensive Care Plan will also be individualized to each resident; -Comprehensive Care Plan will be updated when a change of condition is warranted; [...]

Inspectors wroteBased on observation, interviews, and record reviews, facility staff failed to ensure florescent light bulbs were protected; to maintain kitchen environment equipment in a clean and sanitary manner, and to properly store open food to prevent cross contamination and outdated usage. The facility staff also failed to perform hand hygiene as often as necessary; to wash, rinse, and sanitize the food preparation sink between uses to prevent cross-contamination and the growth of food-borne pathogens and to ensure the ice bin drained through an air gap. This failure had the potential to affect all residents in the facility. The census was 58 with a capacity of 98. 1. Review of the facility's Weekly Preventative Maintenance Checklist, undated, showed: - The policy did not address the kitchen lights; - The policy did not address protecting light bulbs. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide a comfortable and homelike environment, when staff failed to ensure resident areas were in good repair. Additionally, staff failed to ensure one resident's (Resident #12) wheelchair was free of rips and tears. The facility census was 58. Review of the policies provided by the facility showed they did not contain a policy for environmental concerns. 1. Observations from 2/21/23 at 10:45 A.M. through 2/24/23 at 3:00 P.M., showed the 100 hall walls with chipped paint and black marks. Further observation showed multiple door frames with broken trim and the spa with missing baseboard. 2. Observation on 2/22/23 at 1:47 P.M., showed room [ROOM NUMBER] with a sticky floor, and gouged walls. 3. Observation on 2/22/23 at 4:30 P.M., showed room [ROOM NUMBER] with a torn floor mat, and walls with missing paint. 4. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure medications were stored in a safe manner, by not ensuring medications were contained in their original package and properly labeled in one medication cart on the Special Care Unit (SCU). Additionally, facility staff failed to maintain a correct count of controlled medications for two residents (Resident #37 and Resident #39). The facility census was 58. Review of the facility's Storage of Medications Policy, dated March of 2015, showed: -Medications must be stored in the container in which they are received; -Drugs must be stored in an orderly manner in cabinets, drawers or carts. 1. Observation on 2/21/23 at 3:00 P.M., showed the SCU medication cart with loose pills scattered throughout the drawers. Further observation showed the drawers contained the following pills: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment when staff failed to use appropriate hand hygiene and infection control procedures during the provision of care for two residents (Resident #1 and #13), and during wound care for one resident (Resident #1). Additionally, facility staff failed to decrease the risk of infection when staff failed to ensure sanitary conditions for oxygen tubing for one resident (Resident #12) and a urinary catheter (tube placed in the bladder to drain urine) drainage bag for one resident (Resident #24). The facility census was 58. 1. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain resident dignity when staff failed to sit and interact while assisting two residents (Resident #1 and Resident #39) during meal time and failed to allow one resident (Resident #17) access to his/her bathroom. The facility census was 58. Review of the facility's Patient [NAME] of Rights, undated, showed each resident shall be treated with consideration, respect and full recognition of his/her dignity and individuality, including privacy in treatment and care of his/her personal needs. Review of the facility's Resident Rights document, undated, showed: -The resident has a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside of the facility. A facility must protect and promote the rights of each resident; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to post the telephone number for the Department of Health and Senior Services (DHSS) Adult Abuse and Neglect Hotline (used to report allegations of abuse and neglect) in a form and manner accessible to residents and visitors, and failed to post the name, address and phone number for the Long-Term Care Ombudsman and resident rights on the secured unit. The facility census was 58. Review of the facility's Resident Rights policy, undated, showed: -The resident has a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility; [...]