Martha and Mary Health Service

In the surveyor’s words

From the most serious findings on record at Martha and Mary Health Service, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Oct 20, 2022

  Based on observation, interview, record review, and policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner to prevent the potential spread of food borne illness to 108 of 111 residents (three residents received nutrition via feeding tubes). Specifically, the sanitizer solution did not register having any sanitizer present, a staff member failed to don a hairnet in the kitchen, and shakes were not properly dated. Findings include: Review of the Sanitation & Infection Control Food Safety policy dated January 2016 revealed All facilities will adhere to the food safety standards described in the HACCP [Hazard Analysis Critical Control Point] Food Safety Program Manual .Employees wear approved hair restraints . […]

• No harm, potential for more than minimal, patternF684Feb 13, 2026

  Based on interview and record review, the facility failed to initiate the bowel protocol and accurately document bowel protocol interventions for 4 of 6 sampled residents (Resident 12, 8, 58 & 63) reviewed for bowel care. The failure to initiate and document bowel care, placed residents at risk for pain/discomfort, unmet care needs and other potentially negative health outcomes.Findings included . Review of facility policy titled, Bowel Management, dated January 2024, documented, If no BM [bowel movement] for 3 days or more, offer Bowel meds of resident choice listed below, along with non- pharmacological Interventions . MiraLAX 17gm [grams] in 4 – 8oz [ounce] of fluid, applesauce or pudding, PO [by mouth] QD [everyday] / PRN [as needed] no BM x 2 days. […]

• No harm, potential for more than minimal, patternF692Feb 13, 2026

  Based on interview, and record review, the facility failed to ensure fluid intake was accurately monitored, documented, and assessed for 2 of 2 residents (Residents 16 & 4) reviewed with a fluid restriction. The failure to accurately record fluid intake and to calculate the 24-hour fluid intake total, precluded staff from determining if residents was adherent with or were exceeding the fluid restriction. This placed residents at risk for fluid volume overload, fluid and electrolyte imbalances, unidentified education needs and other medical complications. […]

• No harm, potential for more than minimal, patternF880Feb 13, 2026

  Based on interview and record review, the facility failed to provide documentation of records and evidence of real time analysis of their infection control program for 2 of 6 months (December 2025 and January 2026) reviewed for monthly line listings, monthly maps and/or monthly summaries for the facility's surveillance program. These failures could prevent the facility from identifying trends and implementing interventions that would prevent residents from acquiring facility related infections.Findings included.The facility's policy titled Infection Surveillance. dated 11/2025, documented Monthly time periods will be used for capturing and reporting data. Line charts will be used to show data comparisons over time and will be monitored for trends. […]

• No harm, potential for more than minimal, patternF657Dec 16, 2024

  Based on observation, interview and record review, the facility failed to ensure resident care plans (CPs) were reviewed, revised, and accurately reflected residents' care needs for 6 of 25 sampled residents (Residents 73, 99, 81, 8, 11 and 91) whose care plans were reviewed. These failures placed residents at risk for unmet care needs and diminished quality of life. Findings included . 1) Resident 73 admitted to the facility on [DATE]. Review of the Annual Minimum Data Set (MDS, an assessment tool) showed the resident had severe cognitive impairment, diagnoses of dementia with agitation, and anxiety and depressive disorders. Resident 73 required treatment with antidepressant, antianxiety, and antipsychotic medications during the assessment period. […]