Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Mary Health Care Center during CMS and state inspections, most recent first.
A resident with a severe left-hand contracture did not receive effective ROM/contracture care when nursing continued signing off on a hand cone order that was not in place and could no longer adequately position rolled gauze in the hand. OT had documented the hand was extremely tight and painful, but staff did not alert OT when the contracture worsened. When OT later reassessed the hand, dead skin, maceration, and a strong odor were found in the palm, and the resident remained at risk for skin breakdown.
Lack of Tube Feeding Competency Validation for Nursing Staff: The facility failed to ensure an LPN had competency in tube feeding care before providing enteral feeding services to a resident with gastrostomy status, dysphagia, and severe cognitive impairment. During observation, the LPN administered 828 ml of water through the G-tube when the order was for 350 ml, and later acknowledged giving more fluid than ordered. The SDC, DON, and Administrator confirmed there was no tube feeding competency completed for licensed nursing staff.
Failure to document resident participation in care plan meetings: one resident with COPD, schizophrenia, and intact cognition said he/she was invited but did not know where the meetings were held, while the record did not show participation, refusal, or a rationale for nonparticipation; the HCP declined to attend. Two residents with Alzheimer’s disease and severe cognitive impairment also had scheduled care plan meetings, but the record did not show they were invited, attended, refused, or that participation was not practicable.
Incorrect Enteral Flush Volume and Lack of Tube Feeding Competency: A resident with a G-tube, dysphagia, and severe cognitive impairment had an order for 350 mL free water flushes every 4 hours, but an LPN administered 828 mL during an observed flush by repeatedly refilling a 60 mL syringe from a cup. The LPN acknowledged the extra fluid was not ordered, and the DON and SDC stated there were no tube-feeding competencies or training for licensed nurses before the nurse cared for the resident.
Unsecured medication cart and exposed resident information: An LPN prepared multiple meds, crushed them, and left the cup of crushed meds, eye drops, and inhalers on top of an unlocked med cart while stepping away on the Dementia Unit. The cart was unattended in the hallway with residents and staff passing by, and the computer screen with private resident information was left open and visible. The DON stated staff were expected to secure meds inside the cart when walking away and that leaving the screen open was a HIPAA violation.
Unsafe food storage and sanitation practices were observed in the kitchen and beverage areas. Surveyors found unlabeled and undated food items, leftovers kept beyond the facility’s 72-hour limit, a dirty freezer and blender with dried food debris, and cleaning chemicals stored directly on top of juice concentrate boxes. Dietary staff and the FSD acknowledged the items were improperly stored or not cleaned, and that the chemicals could contaminate the juice station.
Failure to Offer Eligible Pneumococcal Vaccine: A resident admitted with pneumonia, asthma, and CKD had prior PPSV23 and PCV13 immunizations, but there was no evidence that PCV20 or PCV21 was offered when the resident became eligible. The IP stated he was responsible for reviewing pneumococcal consent and eligibility, and acknowledged he should have contacted the invoked HCP to offer the vaccine but did not.
A resident with Type 2 Diabetes Mellitus and dementia did not receive routine diabetes monitoring, including overdue HgA1c testing and assessment for signs of hypo/hyperglycemia, despite care plan requirements. Nursing staff failed to recognize or act on the resident's diabetes diagnosis during a significant change in condition, resulting in critically high blood glucose and hospital admission for hyperosmolar hyperglycemic state.
A resident with severe dementia and an invoked Health Care Agent (HCA) developed new skin issues, including MASD and a fluid-filled blister, both requiring new physician-ordered treatments. Facility staff did not notify the HCA of these changes, and documentation of notification was missing or incomplete, despite facility policy and protocol requiring such notification.
Several alert residents reported that a nurse repeatedly treated them without dignity or respect, including yelling, using a curt or aggressive tone, withholding medications, and handling medications roughly. Staff interviews supported these accounts, describing the nurse as lacking compassion and speaking rudely or condescendingly to residents. These actions violated residents' rights to be treated with dignity and respect.
The facility failed to complete a Significant Change in Status Assessment (SCSA) within the required 14-day timeframe for two residents. One resident experienced a decline in bowel and bladder function and developed a Stage 3 pressure injury, while another was admitted to hospice services. The MDS Nurse acknowledged the delays, citing unawareness of the hospice admission as a reason for the oversight.
The facility failed to conduct required PASRR assessments for two residents after significant changes in their mental health conditions, including new diagnoses and medication adjustments. Despite these changes, the necessary screenings were not completed, as confirmed by the Social Worker.
A facility failed to remove hazardous items from a resident's room, who had a history of suicidal ideation and cognitive impairment. Surveyors found disposable razor blades on the resident's bedside table, despite the resident's known history of self-harm attempts. The facility's policy required hazardous items to be removed, and interventions were in place to ensure safety, but these were not followed.
A resident with a history of mental health issues expressed a plan to self-harm, but the facility failed to provide timely psychiatric assessment and continuous monitoring. Despite initial actions by the DON, the resident was not seen by psychiatric services until three days later, contrary to facility policy.
The facility failed to ensure timely re-ordering of Insulin E-Kits on the Fourth and Fifth Floor Units, as required by their policy. The E-Kits were opened and medications removed, but there was no evidence of re-ordering from the pharmacy, which should have occurred the same day. Nurses acknowledged the oversight, which deviated from the facility's procedures.
A facility failed to conduct regular laboratory tests for a resident as ordered by the physician. Despite an active order for blood tests, including FSBS, WBC, ANC, and BMP, only a WBC and BMP draw was completed on one occasion. The resident, with diagnoses including Schizophrenia and Major Depressive Disorder, was moderately cognitively impaired. Interviews confirmed the order was still active, but there was no evidence of the tests being performed as required.
A facility failed to perform EKG testing every six months for a resident with heart failure and on antipsychotic medication, as ordered by the physician. Despite an active order, no EKGs were documented since 2023. Interviews with the UM and DON confirmed the oversight and lack of evidence for completed tests.
A resident with a sacro-coccyx wound did not receive proper infection control during wound care. Nurse #1 failed to perform hand hygiene between glove changes, contrary to facility policy and CDC guidelines. This lapse was acknowledged by both the nurse and the DON, highlighting a risk of infection for the resident.
The facility did not post the required daily nurse staffing information, omitting total and actual hours worked by RNs, LPNs, LVNs, and CNAs. Additionally, the facility failed to maintain staffing records for 18 months as required. The Administrator was unaware of these requirements.
Failure to Maintain Hand ROM and Contracture Care
Penalty
Summary
The facility failed to provide appropriate assistance to maintain left-hand range of motion for a resident with a left-hand contracture. The resident was admitted with diagnoses including cognitive impairment and need for assistance with personal care, and the clinical record showed a left-hand contracture diagnosed in September 2025. The care plan included rolled gauze for contracture management, and the resident’s MDS indicated severe cognitive impairment, dependence for ADLs, impaired upper extremity ROM on one side, and recent OT services. An OT evaluation in December 2025 documented that the resident’s left hand was extremely tight due to spasticity, that the OT was barely able to get the fingers off the palm, that the resident yelled with attempts to open the hand, and that the resident was at high risk for skin breakdown because the fingernails were contacting the skin. Physician orders later directed nursing to wash the hand, pat it dry, and apply a hand cone with Velcro strap to keep the fingers off the palm, with removal only for skin care. OT treatment notes in January 2026 stated the resident required maximum effort to open the hand for gauze placement, had not made progress despite increased Baclofen, and nursing staff were changing the rolled gauze daily. During observations in April 2026, the resident’s left hand was seen in a fisted position without the hand cone in place. The TAR showed the hand cone and hand treatment were signed off as completed daily, but nursing staff told the surveyor the resident’s hand was too contracted to place the rolled gauze as ordered and that the resident had been like that for about a month. Nursing also acknowledged signing off on the hand cone order even though the resident did not have a hand cone. The OT stated that if nursing could no longer place the rolled gauze because of the worsening contracture, a referral should have been made for OT reassessment. When the OT reassessed the hand after surveyor inquiry, she found dead skin in the palm, maceration at the base of the pinky finger, and a strong odor, and stated the resident remained at risk for skin breakdown.
Lack of Tube Feeding Competency Validation for Nursing Staff
Penalty
Summary
The facility failed to ensure that nurses and nurse aides had the competencies needed to care for residents requiring tube feeding. The facility assessment dated 10/1/25 identified specialized care such as tube feedings as a competency area, and the facility policy stated that employee competency is evaluated through the training program and orientation process. However, the assessment did not indicate the nursing competencies and skill set necessary to provide tube feeding care, and the facility had no documented nursing competency process for tube feeding care and services. Resident #12 was admitted with diagnoses including Multiple Sclerosis, gastrostomy status, dysphagia, oral phase feeding difficulties, and obstructive sleep apnea. The resident’s MDS dated 1/6/26 showed severe cognitive impairment with a BIMS score of 7, and the resident received nutrition and hydration via feeding tube, including more than 51% of calories through tube feeding and more than 501 cc of fluid per day through the tube. Physician orders included free water flushes via G-tube of 350 ml every 4 hours and enteral nutrition via pump from 6:00 P.M. to 6:00 A.M. On 4/9/26, Nurse #3 was observed providing enteral tube feeding care and assessed gastric residual volume, then administered water through the feeding tube using a 60 ml syringe and a large styrofoam cup. The nurse stated the cup held 350 ml, but later measured the amount and found that 828 ml had been administered, which was 478 ml more than ordered. Nurse #3 acknowledged that she gave more fluid than the physician ordered and stated that she was not competent in enteral tube feeding care and had not received facility training or competency validation for tube feeding. The SDC, DON, and Administrator each confirmed that no tube feeding competency had been completed for licensed nursing staff.
Failure to Document Resident Participation in Care Plan Meetings
Penalty
Summary
The facility failed to ensure that residents were given the right to participate in their care plan process and that the record documented when participation was not practicable. The report states that the interdisciplinary team was required to develop comprehensive, person-centered care plans with the resident and, when applicable, the resident’s family or legal representative, and that advance notice of care planning conferences was to be provided. It also states that if resident participation was not practicable, the reason and the steps taken to include the resident or representative were to be documented in the medical record. For Resident #96, who was admitted with COPD and schizophrenia and was cognitively intact with a BIMS score of 15/15, the resident said he/she had been invited to care plan meetings but did not know where they were held. The clinical record did not show that the resident participated in the care plan reviews held on multiple occasions, did not document a refusal or rationale for nonparticipation, and did show that the healthcare proxy was invited and declined to attend on several occasions. The care plan invitations also did not indicate the meeting location or that the resident needed to call the social worker to confirm attendance. The social worker stated there was no documented evidence that the resident declined to attend, and the DON stated the resident should have been invited because the meetings were about the resident and the resident deserved a voice in the plan of care. For Resident #1, who had Alzheimer’s disease and severe cognitive impairment with a BIMS score of 2/15, the record showed care plan meetings were scheduled but the attendance sheets did not show the resident attended. The clinical record did not document that the resident was invited, did not show any refusal, and did not explain why the resident was absent or why participation was not practicable. For Resident #5, who also had Alzheimer’s disease and severe cognitive impairment, the record showed scheduled care plan meetings, but attendance sheets did not show the resident attended. The record did not document an invitation, a refusal, or any rationale that participation was not practicable. The social worker and DON both stated there was no evidence that Residents #1 and #5 were invited or that their nonparticipation had been documented as not practicable.
Incorrect Enteral Flush Volume and Lack of Tube Feeding Competency
Penalty
Summary
The facility failed to provide necessary care and services related to enteral feeding for one resident with a gastrostomy tube. The resident was admitted with diagnoses including Multiple Sclerosis, gastrostomy status, dysphagia, oral phase feeding difficulties, and obstructive sleep apnea, and the MDS indicated severe cognitive impairment with a BIMS score of 7. The resident received nutrition and hydration through the feeding tube and had a physician order for free water flushes via G-tube of 350 mL every 4 hours for hydration, along with enteral nutrition by pump from 6:00 P.M. to 6:00 A.M. During observation, the surveyor saw a nurse assess gastric residual volume and then attach a 60 mL catheter-tip syringe to the enteral tube. The nurse removed the plunger and repeatedly refilled the syringe barrel from a large styrofoam cup, allowing water to flow into the resident's stomach. The resident stated, "you are making me heavy with all that water." The nurse told the surveyor the cup held 350 mL and that the resident had an order for 350 mL every 4 hours, but when the surveyor measured the cup contents using a 207 mL plastic cup, the total amount was 828 mL. The nurse acknowledged that 828 mL had been administered instead of the ordered 350 mL and stated that 478 mL of fluid had been given without a physician order. The nurse identified the risks as aspiration, fluid overload, and pneumonia. The Staff Development Coordinator and the Director of Nursing stated that there were no licensed nursing competencies or training related to tube feeding care and services for the licensed nurses before the nurse worked with the resident, and the nurse also stated she had not received prior training or education specific to enteral feeding tube care before caring for this resident.
Unsecured medication cart and exposed resident information
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored in accordance with professional requirements on the Dementia Unit (Third Floor Side A). During an observation on 4/10/26, Nurse #1 prepared multiple medications, including lisinopril, azathioprine, vitamin D, aspirin, folic acid, furosemide, mesalamine DR, trazodone, albuterol HFA, cyclosporine ophthalmic emulsion, Serevent Diskus, and artificial tears. The nurse crushed the medications, placed them in a clear plastic cup with applesauce, and then walked away from the medication cart and entered the unit dining room, leaving the cup of crushed medications, eye drops, and inhalers on top of the cart. The medication cart was left unlocked, and the computer screen with private resident information remained open and visible while staff and residents walked by in the hallway. The surveyor later observed that Nurse #1 returned to the cart and moved it to another location in the hallway, but the eye drops and inhaler medications were still left on top of the cart, which remained unattended and unsecured, with the computer screen still unlocked. During interview, Nurse #1 stated that medication carts should be locked and medications put away when unattended, and that leaving crushed medications, inhalers, and eye drops on the cart allowed access by staff and residents. Nurse #1 also stated the computer screen should have been secured to protect resident information. The DON stated that nursing staff were expected to secure medications inside the cart when walking away, especially on the Dementia Unit where wandering residents could access an unlocked cart, and that leaving the computer screen open was a HIPAA violation.
Unsafe Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure that food was stored in a safe and sanitary manner in accordance with professional standards for food service safety. During observation of the main kitchen, surveyors found multiple food items in the walk-in refrigerator that were unlabeled, undated, or dated beyond the facility’s 72-hour limit for leftover food. These included a wrapped shredded chicken breast and a clear container of cottage cheese that were unlabeled and undated, as well as pans of rice and pasta that were dated 4/3/26 and 4/1/26. The dietary staff member interviewed at the time stated these items should have been labeled, dated, covered, and discarded within three days. In the reach-in refrigerator, surveyors observed a container of chunked pineapple dated 3/26/26, fruit cocktail dated 4/3/26, apple slices dated 4/3/26, an unlabeled and undated yellow substance identified as applesauce, and a box of muffins with ripped plastic wrap that was undated. The dietary staff member stated the pineapple, fruit cocktail, and apple slices should have already been discarded, and that the applesauce should have been labeled and dated before refrigeration. The staff member also stated the muffins should have been completely covered and dated when opened before being returned to the refrigerator. Surveyors also observed a silver reach-in freezer with splattered white and brown substances on the outer doors, handles, inner walls, and floor, along with green, red, and brown debris on the inner compartment walls and floor. A Ninja blender had dried red, brown, and white splatters on the control buttons, sides, and rotation platform, including dried solid chunks of white matter. In addition, two red buckets of cleaning solution were stored directly on top of juice concentrate boxes at the juice station. The Food Service Director stated the freezer debris appeared to be spilled food that should have been wiped up, the blender should have been cleaned, and the chemicals should not have been left on top of the juice concentrate boxes because the juice station could be contaminated.
Failure to Offer Eligible Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that Pneumococcal Vaccination was offered to one resident who was eligible for PCV20 or PCV21 at the time of admission. Resident #1 was admitted in December 2025 with diagnoses including pneumonia, asthma, and chronic kidney disease, and had an invoked HCP effective 11/13/25. The medical record showed prior pneumococcal immunizations of PPSV23 on 11/5/10 and PCV13 on 1/10/20, but there was no evidence that PCV20 or PCV21 had been offered. During interview, the Infection Preventionist stated the facility followed CDC guidance for pneumococcal immunizations and that he was responsible for ensuring Pneumococcal Consent Forms were completed correctly and reviewed for eligibility. He stated Resident #1 was at high risk for exposure to pneumonia due to age and nursing home residence, was eligible to receive PCV20 or PCV21 in November 2025, and that he should have approached the resident’s HCP to inform them the immunization was not up to date and offer vaccination, but did not.
Failure to Monitor and Manage Diabetes Leading to Hospitalization
Penalty
Summary
A resident with a history of Type 2 Diabetes Mellitus and vascular dementia was not provided with care that met professional standards, as routine laboratory testing to monitor diabetes control was not performed. The resident's last documented Hemoglobin A1c (HgA1c) test was over a year prior, despite facility policy and American Diabetes Association guidelines recommending regular testing. The resident's diabetes was diet-controlled, and the care plan required monitoring for signs and symptoms of hypo/hyperglycemia, but there was no documentation that such monitoring occurred. On a specific day, the resident experienced a significant change in condition, presenting as lethargic, refusing meals, and being unresponsive. Nursing staff, including two nurses assigned to the resident, did not recognize or act upon the resident's diabetes diagnosis during their assessments. One nurse stated she was unaware of the diabetes diagnosis, despite signing off on diabetic foot care in the treatment administration record. Another nurse, who was aware of the diagnosis, could not recall if a finger stick blood sugar was checked, and there was no documentation that this assessment was performed. The resident was eventually found to have a critically high blood glucose level (611 mg/dl) and elevated sodium, leading to transfer to the hospital and admission for hyperosmolar hyperglycemic state and hypernatremia. Interviews with facility staff, including the nurse practitioner and director of nursing, revealed a lack of awareness regarding the overdue HgA1c testing and uncertainty about whether staff were monitoring for diabetes-related complications as required by the care plan.
Failure to Notify Health Care Agent of Resident's Skin Condition Changes
Penalty
Summary
The facility failed to notify a resident's Health Care Agent (HCA) of significant changes in the resident's skin condition, despite the HCA's authority being permanently invoked due to the resident's severe dementia. The resident, who had diagnoses including Type II Diabetes Mellitus and vascular dementia, developed a new area of Moisture Associated Skin Damage (MASD) on the buttocks and a fluid-filled blister on the left foot, both of which required new physician-ordered treatments. Documentation showed that the HCA was not informed of these changes, even though facility policy required notification of the resident's representative when new treatments or significant changes occurred. Interviews with nursing staff revealed that notification to the HCA was either not attempted, not completed, or not documented. One nurse stated that if she had notified the HCA, she would have documented it, but the relevant form was left blank. Another nurse attempted to call the HCA but did not retry when the call did not go through. The Director of Nursing confirmed that it was facility protocol to notify the HCA at the same time as the provider, but there was no evidence in the medical record that this occurred for either the new MASD or the foot blister.
Failure to Treat Residents with Dignity and Respect by Nursing Staff
Penalty
Summary
Multiple residents who were alert and able to communicate their needs reported being treated without dignity and respect by a nurse during the overnight shift. The facility's own policy requires that residents be treated with dignity and respect, recognizing their individuality and accommodating their needs and preferences. However, five residents described consistent patterns of yelling, rudeness, and disrespectful behavior from the nurse, including the use of a curt or aggressive tone, withholding medications, and physically throwing or banging medications onto tables rather than handing them to residents. Specific incidents included residents feeling afraid to ask for assistance due to the nurse's behavior, being spoken to in a sharp, dismissive, or angry tone, and being reprimanded loudly in front of others. One resident recounted being yelled at for requesting medication, while another described the nurse interrupting care and speaking angrily about the use of a bedpan. Staff interviews corroborated these accounts, with other nurses and a CNA noting that the nurse in question was perceived as lacking compassion, being annoyed by resident requests, and speaking in a rude or condescending manner. Additional staff, including a nurse supervisor, observed the nurse moving a resident abruptly and speaking in a loud, reprimanding tone. The consistent and corroborated reports from both residents and staff indicate that the nurse's actions failed to honor the residents' rights to be treated with dignity and respect, as required by facility policy and regulatory standards.
Failure to Complete Timely SCSA for Residents
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for two residents within the required 14-day timeframe following significant changes in their conditions. For one resident, there was a decline in bowel and bladder functioning, along with the development of a Stage 3 pressure injury. Despite these changes, the SCSA was not completed during the most recent assessment period, as confirmed by the MDS Nurse during an interview. Another resident was admitted to hospice services, which also necessitated a SCSA within 14 days. However, the assessment was not completed in the required timeframe because the MDS Nurse was unaware of the hospice admission. The delay in completing the SCSA was acknowledged by the MDS Nurse, who noted that the assessment was initiated much later to capture the resident's current status.
Failure to Conduct PASRR Assessments After Significant Changes
Penalty
Summary
The facility failed to coordinate assessments with the Preadmission Screening and Resident Review (PASRR) program for two residents, leading to deficiencies in their care. Resident #13 experienced significant changes in status, including new diagnoses of Major Depressive Disorder and Delusional Disorders, which required adjustments to psychotropic medications and the care plan. Despite these changes, the facility did not complete a new Level I PASRR assessment as required. The Social Worker acknowledged that a new PASRR screening should have been submitted when these diagnoses were added to the resident's profile, but it was not done. Similarly, Resident #84 was admitted with diagnoses including Unspecified Dementia and later had a new diagnosis of Psychotic Disorder with delusions added to their clinical record. This change also necessitated adjustments to antipsychotic medications and the care plan. However, the facility again failed to conduct a new Level I PASRR screening. The Social Worker confirmed that a new PASRR screening should have been submitted when the new diagnosis was added, but it was not completed. These oversights indicate a failure to adhere to federal requirements for PASRR assessments following significant changes in residents' mental health conditions.
Failure to Remove Hazardous Items for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to ensure a safe environment for a resident with a history of suicidal ideation and cognitive impairment. During an observation, surveyors found three disposable razor blades on the resident's bedside table, which were easily accessible. This oversight occurred despite the resident's known history of self-harm attempts, including breaking a fork to create a weapon. The facility's policy required that such hazardous items be removed from the resident's room, and interventions were in place to provide plastic utensils and ensure razors were only given by nurses. The resident, who had been admitted with diagnoses of anxiety, major depressive disorder, and cognitive communication deficit, was under the guardianship due to their inability to make personal decisions. The resident's care plan included monitoring for suicidal thoughts and ensuring safety by removing potential hazards. However, the presence of razor blades in the resident's room indicated a lapse in following these safety protocols. Interviews with the Unit Manager and the Director of Nursing confirmed that the razors should not have been accessible to the resident.
Failure to Provide Timely Mental Health Services
Penalty
Summary
The facility failed to provide timely mental health services to a resident with a documented history of mental health concerns, including anxiety, major depressive disorder, and cognitive communication deficit. The resident expressed a plan to self-harm by making a weapon out of a fork, which was documented on 2/12/24. Despite the facility's policy requiring immediate action and psychiatric consultation, the resident was not assessed by a physician or psychiatric services until three days later, on 2/15/24. During this period, there was no documentation of continuous monitoring for the resident's safety. Interviews with facility staff revealed that the Director of Nursing (DON) was aware of the resident's suicidal ideation and had taken some initial steps, such as removing potential weapons from the resident's room and making a verbal safety contract. However, the facility did not provide one-on-one supervision or send the resident for an emergency psychiatric evaluation, as expected by the social worker. The physician confirmed being notified of the situation but was not present at the facility when the resident expressed suicidal thoughts. The lack of timely assessment and continuous monitoring constituted a failure to adhere to the facility's policies for addressing suicide threats and providing necessary behavioral health services.
Failure to Re-Order Insulin Emergency Kits
Penalty
Summary
The facility failed to ensure that pharmaceutical services were adequately provided to meet the needs of each resident, specifically in the management of Insulin emergency medication kits (E-Kits) on the Fourth and Fifth Floor Units. The facility's policy required that E-Kits be re-ordered and replaced by the pharmacy promptly after being opened. However, observations and interviews revealed that the Insulin E-Kits were not re-ordered in a timely manner after being opened, which is a deviation from the facility's policy. On the Fifth Floor, the Insulin E-Kit was opened on 7/22/24, with medications removed on 7/22/24 and 12/15/24, but there was no evidence that the kit was re-ordered from the pharmacy. Similarly, on the Fourth Floor, the E-Kit was opened on 12/10/24, and medication was removed, but again, there was no evidence of re-ordering. Nurses on both floors acknowledged the failure to re-order the kits as per the policy, which required re-ordering on the same day the kit was opened and expected delivery by the next business day.
Failure to Conduct Regular Laboratory Tests for Resident
Penalty
Summary
The facility failed to provide necessary laboratory services for a resident, identified as Resident #33, who was part of a sample of 21 residents. The deficiency was identified through a review of records and interviews, revealing that the facility did not conduct required blood tests every three months as ordered by the resident's physician. The resident, who was admitted in November 2017, had diagnoses including Schizophrenia, Major Depressive Disorder, and Benign Prostatic Hyperplasia. The resident's most recent Minimum Data Set assessment indicated moderate cognitive impairment. Despite an active physician's order from December 6, 2021, for specific blood tests, including fingerstick blood sugar (FSBS), white blood cell count (WBC), absolute neutrophil count (ANC), and Basic Metabolic Panel (BMP), the facility only completed a WBC and BMP blood draw on September 20, 2024. The clinical record showed no evidence that the ANC and FSBS tests had been completed since the order was issued, nor that the WBC and BMP tests were conducted at any other time besides the September 2024 draw. Interviews with the Unit Manager and the Director of Nursing confirmed that the order for these blood tests was still active as of December 16, 2024, yet they were unable to provide evidence that the tests were performed as ordered. This failure to adhere to the physician's orders for regular laboratory testing constitutes a deficiency in the facility's provision of care.
Failure to Provide Required EKG Testing for Resident
Penalty
Summary
The facility failed to provide or obtain necessary diagnostic services for a resident, specifically neglecting to perform electrocardiogram (EKG) testing every six months as ordered by the resident's physician. The resident, who was admitted in January 2022, had diagnoses including Unspecified Systolic Congestive Heart Failure, Major Depressive Disorder, and Borderline Personality Disorder, and was on antipsychotic medication. Despite an active order dated July 10, 2022, for EKGs every six months, there was no evidence in the clinical record that any EKGs had been completed since 2023. Interviews with the Unit Manager and the Director of Nursing revealed that the orders for the EKGs were not followed, and there was a lack of documentation to confirm that the tests had been performed. The Unit Manager acknowledged the oversight and mentioned that the order should have been completed or clarified with the physician. The Director of Nursing confirmed the active order for EKGs and was unable to provide evidence of any completed tests in the past year, indicating a lapse in the facility's adherence to the physician's orders for monitoring the resident's condition.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to adhere to infection control standards during wound care for a resident with a sacro-coccyx wound. The resident, who was admitted in October 2020, had a history of Alzheimer's Disease, Atrial Fibrillation, Congestive Heart Failure, and a Stage 4 pressure injury. The facility's policy required hand hygiene before and after glove use, and the resident's care plan included Enhanced Barrier Precautions to prevent infection. However, during an observation, Nurse #1 did not perform hand hygiene between glove changes multiple times while providing wound care, which was against the facility's policy and CDC guidelines. During the procedure, Nurse #1 and a CNA initially performed hand hygiene and donned protective equipment. However, Nurse #1 repeatedly changed gloves without using hand sanitizer or washing hands, even after handling soiled dressings and touching the wound. This lapse in protocol was acknowledged by Nurse #1, who admitted to not performing hand hygiene appropriately, and by the Director of Nursing, who confirmed that the nurse should have followed the recommended guidelines. This failure to perform proper hand hygiene put the resident at risk for infection.
Failure to Post and Maintain Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information, which includes the total number and actual hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs), and Certified Nurses Aides (CNAs) per shift. During a survey, it was observed that the nurse staffing postings in the front lobby on specific days in December 2024 did not include the necessary details. Additionally, the facility did not maintain a copy of the staffing records for the required 18 months. The Administrator admitted to being unaware of the requirement to include actual and total hours worked in the postings and acknowledged the failure to maintain the records for the specified duration.
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Illustrative
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Worcester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West Side House Ltc Facility | 0.7 mi | ★★★★★ | 17 | 0 |
| Lutheran Rehabilitation And Skilled Care Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Worcester Rehabilitation & Health Care Center | 1.3 mi | ★★★★★ | 1 | 0 |
| Vantage At Worcester Llc | 1.5 mi | ★★★★★ | 14 | 0 |
| St Francis Rehabilitation & Nursing Center | 1.6 mi | ★★★★★ | 5 | 0 |
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