St. Mary Health Care Center

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide appropriate assistance for one Resident (#3) out of a total sample of 23 residents, to maintain left-hand range of motion (ROM) when the Resident had a left-hand contracture. Specifically, the facility failed to adequately identify and treat Resident #3's left-hand contracture in a timely manner, when the severity of the Resident's left-hand contracture changed, increasing the Resident's risk for further decrease in ROM and skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that competency and skills necessary to provide the level and type of care needed for one Resident (#12) were demonstrated by one Licensed Nurse (Nurse #3). Specifically, the facility failed to ensure that Nurse #3 completed the necessary training and competencies relative to gastrointestinal feeding tube management prior to providing tube feeding care and services for Resident #12.

Inspectors wroteBased on interviews and records reviewed, the facility failed to ensure that three Residents (#96, #1 and #5) out of a total sample of 23 residents were provided the right to participate in the care plan process. Specifically, the facility failed to: 1. For Resident #96, ensure that the Resident was provided with the required information for participation in the care planning process when he/she was not informed of where the care meetings were held and the facility did not provide rationale why the Resident's participation in the care planning process was not practicable when the Resident's Healthcare Proxy declined to attend.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services relative to enteral feeding (delivery of nutrients through a feeding tube into the stomach/intestines), for one Resident (#12) out of a total sample of 23 residents. Specifically, for Resident #12, the facility failed to ensure that the accurate amount of water flushes as ordered by the Physician, and the appropriate tube feed flush procedure was being administered via the Resident's enteral feeding tube, when more than the ordered amount of water flushes was administered, placing the Resident at risk for gastrointestinal complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that drugs and biologicals were stored in accordance with professional requirements on one unit's (Dementia Unit -Third Floor Side A) medication cart, out of a total of three units reviewed. Specifically, the facility failed to ensure that a medication cart on the Third floor Side A was locked, and prepared medications were secured when the medication cart were left unattended, to prevent unauthorized personnel and residents' access to medications on and in the medication cart.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that food was stored in a safe and sanitary manner, in accordance with professional standards for food service safety to prevent the spread of foodborne illness. Specifically, the facility's dietary staff failed to: -ensure food items were properly labeled and dated in the main kitchen refrigerators placing residents at risk for food borne illness. -discard left over food within 72 hours that had been clearly labeled and dated, placing residents at risk for foodborne illness. -maintain a clean and sanitary food storage freezer, stove, and blender used for the storage or preparation of resident food placing residents at risk for food borne illness. -store chemicals away from the drink station, placing residents at risk for receiving contaminated beverages.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that Pneumococcal Vaccination was offered as required to one Resident (#1), of five applicable residents reviewed for Pneumococcal immunization, out of a total sample of 23 residents. Specifically, for Resident #1, the facility failed to offer Pneumococcal Vaccination to the Resident when he/she was eligible for Pneumococcal Vaccination PCV20 or PCV21 (Pneumococcal Conjugate Vaccine: vaccine used to protect against 20 and 21 types of pneumococcal bacteria that commonly cause serious infections) at the time of admission to the facility.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure he/she was provided with quality of care that met professional standards of practice, when he/she did not receive routine laboratory testing to ensure his/her Type 2 Diabetes Mellitus was controlled, when on 09/12/25 he/she experienced a significant change in condition, was found to be hyperglycemic (elevated blood sugar level) with critically high blood sugar reading, he/she required transfer to the Hospital Emergency Department (ED) for evaluation and was admitted for treatment.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents, (Resident #1), who had an invoked Health Care Proxy, the facility failed to ensure his/her representative was notified when he/she developed an alteration of his/her skin integrity to his/her buttocks and a fluid filled blister on his/her left foot, requiring physician ordered treatments.

Inspectors wroteBased on records reviewed and interviews, for 5 of 5 sampled residents (Residents #1, #2, #3, #4 and #5), who were alert and able to made their needs known, the Facility failed to ensure they were treated in a dignified and respectful manner, when they all reported that Nurse #1 responded to their request for assistance with yelling, rudeness and disrespect.

Inspectors wroteBased on interview, and record review, the facility failed to identify and complete in the required time frame, a Minimum Data Set (MDS) for a Significant Change in Status Assessments (SCSA) for two Residents (#9 and #34) out of a total sample of 21 residents. Specifically, the facility failed to: 1. For Resident #9, complete a SCSA within 14 days after the Resident had a decline in bowel functioning, bladder functioning, and a new pressure injury. 2. For Resident #34, complete a SCSA within 14 days after the Resident was admitted to a Hospice program.

Inspectors wroteBased on record review, and interview, the facility failed to coordinate an assessment with the Preadmission Screening and Resident Review (PASRR - a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) program for two Residents (#13 and #84) out of a total sample of 21 residents. Specifically, the facility failed to complete a new Level I PASRR Assessment for: 1. For Resident #13, when there was a significant change in status on two dates with behavioral changes identified, new diagnoses of Major Depressive Disorder on 11/30/23 and Delusional Disorders on 7/30/24, were added to the Resident's clinical record, and adjustments to the Resident's psychotropic medication and plan of care were made. 2. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the environment was free from accidents and hazards for one Resident (#24) out of a total sample of 21 residents. Specifically, the facility failed to ensure hazardous items (razor blades) were not stored on the Resident's bedside table and easily accessible to Resident #24, who had a history of suicidal ideation (thoughts or ideas centered around death or self-harm) and other cognitively impaired residents on the unit.

Inspectors wroteBased on record review, and interview, the facility failed to provide mental health services for one Resident (#24) out of a total sample of 21 residents, with a documented history of mental health concerns. Specifically, the facility failed to assess Resident #24's mental health status in timely manner after he/she expressed a plan to self-harm.

Inspectors wroteBased on observation, and interview, the facility failed to ensure that pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) were available to meet the needs of each resident in the facility for two medication storage rooms (Fourth and Fifth Floor Units). Specifically, the facility failed to ensure that Insulin (medication used to treat Diabetes) emergency medication kits (E-Kits) were re-ordered and replaced timely by the Pharmacy after being opened. Findings Include: Review of the facility Pharmacy policy titled Emergency Kit Policy & Procedure dated 01/01/2024, indicated the following: -A portable emergency kit or kits shall be made available for immediate administration of a medication not otherwise obtainable in the time required. [...]

Inspectors wroteBased on record review, and interview, the facility failed to provide laboratory services for one Resident, (#33), out of a total sample of 21 residents. Specifically, the facility failed to obtain blood tests every three months for Resident #33 as ordered by the Resident's Physician.

Inspectors wroteBased on record review, and interview, the facility failed to provide or obtain diagnostic services for one Resident (#4) out of a total sample of 21 residents. Specifically, the facility failed to provide electrocardiogram (EKG- a test which records the electrical activity of the heart through repeated cardiac cycles) testing every six months for Resident #4 as ordered by the Resident's Physician for monitoring of antipsychotic medication use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to infection control standards to prevent the potential transmission of communicable diseases and infections for one Resident (#9) out of a total sample of 21 residents. Specifically, the facility failed to ensure that staff performed proper hand hygiene between glove changes while providing wound care to Resident #9 to prevent contamination and the spread of infections.

Inspectors wroteBased on record review, and interview, the facility failed to post the required nurse staffing information daily. Specifically, the facility failed to: -post the total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: >Registered Nurses (RN), >Licensed Practical Nurses (LPN) or Licensed Vocational Nurses (LVN), >and Certified Nurses Aides (CNA). -maintain a copy of the staffing records for 18 months as required.

Inspectors wroteBased on observations, interviews, and policy and records reviewed, the facility failed to adhere to infection control guidelines to prevent contamination and the potential spread of infection. Specifically, the facility failed to: 1. Ensure that staff doffed (removed) personal protective equipment (PPE) when exiting a COVID-19 positive resident's room; and 2a. Ensure PPE was doffed as required after exiting a COVID positive resident room (Resident #55), and b. that social distancing was maintained for one Resident (#21), who was identified as having COVID-19, and was seated in the Unit Dining Room with other residents who were COVID-19 negative putting the other residents at increased risk for transmission of the virus.

Inspectors wroteBased on observations, interviews, and policy and records reviewed, the facility failed to ensure feeding assistance was provided for eight Residents (#4, #15, #40, #47, #55, #56, #76 and #78) who resided on two of the three units observed. Specifically, the facility failed to ensure timely meal assistance was provided when the meal had been served for residents determined to need assistance from staff.

Inspectors wroteBased on observations and interviews, the facility failed to ensure that two Residents (#367 and #86), out of a total sample of 25 residents on one (Unit Three) of three units observed were afforded dignity during dining. Specifically, the facility failed to: 1. Provide appropriate clothing for Resident #367 to prevent exposure of his/her backside and incontinence briefs; and 2. Sit while assisting Resident #86 to eat during a meal.

Inspectors wroteBased on interviews, and policy and records reviewed, the facility failed to notify the Physician in a timely manner, of the unavailability and multiple missed doses of the antipsychotic medication Risperidone (a medication used to treat the symptoms of psychosis- a symptom of losing touch with reality) for one Resident (#102), out of a total sample of 25 residents. Specifically, the facility failed to notify the Physician so an alternate medication could be considered when multiple doses of the prescribed medication Risperidone were not administered to Resident #102.

Inspectors wroteBased on interview and records reviewed, the facility failed to refer one Resident (#34) for a Preadmission Screening and Resident Review (PASSAR- a federal requirement to help ensure individuals are not inappropriately placed in long term care) Level II evaluation (an in-depth evaluation of a person who has a positive Level I screen (a preadmission screening process used to determine if a person has a diagnosis or suspected diagnosis of developmental disabilities/related conditions or mental illness) for mental illness (MI), intellectual disability, or related condition to determine if they require specialized services, out of a total sample of 25 residents. [...]

Inspectors wroteBased on interview and records reviewed, the facility failed to ensure one Resident (#97), out of a total sample of 25 residents, was scheduled for a medical appointment to obtain needed services. Specifically, the facility failed to schedule a follow up consultation appointment with a glaucoma specialist after a recommendation from the facility eye doctor.

Inspectors wroteBased on observation, interview, and policy and records reviewed, the facility failed to provide respiratory care in accordance with professional standards of practice for one Resident (#103), out of one applicable sampled resident, in a total sample of 25 residents. Specifically, the facility failed to change Resident #103's oxygen (O2) tubing on a routine basis or place signage outside the Resident's room to indicate Oxygen was in use.

Inspectors wroteBased on observation and interview, the facility failed to ensure its staff posted the daily Nursing staffing data with current information.