Mary Health of the Sick Convalescent & Nursing Hos

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.