Mary Free Bed Sub-Acute Rehabilitation

In the surveyor’s words

From the most serious findings on record at Mary Free Bed Sub-Acute Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF760Oct 21, 2025

  This citation pertains to Intake # 2641086.Based on interview, and record review, the facility failed to ensure residents were free from significant medication errors in 1 of 3 residents (Resident #101) reviewed for significant medication errors, resulting in a change in mental status and hospitalization for Resident #101 when an opioid pain medication was not charted as administered and not documented per physician orders and professional standards of practice.Findings include:Review of an Incident Summary revealed .(Licensed Practical Nurse (LPN) I) did not chart that she administered, but did sign out 20 mg (milligram) Butrans patch on 10/1/25, at 6:22am. […]

• No harm, potential for more than minimal, widespreadF727May 13, 2026

  Based on interview and record review, the facility failed to ensure that they had Registered Nurse (RN) coverage for at least 8 consecutive hours a day for 2 of 30 days (4/26/26 and 5/9/26) reviewed for RN coverage. Findings include:A review of the Daily Staffing Pattern sheets, dated 4/11/26 to 5/12/26, revealed that Registered Nurse/ Licensed Practical Nurse (RN/LPN) hours were not separated by licensure. The Daily Staffing Pattern Sheets had Total Hours (RN) listed. However, those hours were total nursing hours worked versus RN and/or LPN hours worked.A review of the facility's employee list revealed the facility employed both RN's and LPN's.During an interview on 5/13/26 at 8:45 AM, the Nursing Home Administrator (NHA) stated she thought the Total Hours (RN)on the Daily Staffing… […]

• No harm, potential for more than minimal, widespreadF812Apr 16, 2025

  Based on observation, interview, and record review, the facility failed to maintain best practices in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: An initial kitchen/food service tour was conducted on 4/14/25 beginning at 9:26 AM with Director of Dining Services (DDS) X and Clinical Nutrition Manager (CNM) W. The following observations/interviews/record reviews were completed: Food Labeling/Dating/Discarding On 4/14/25 at 9:38 AM in the cooler underneath the juice machine, there was a half-gallon container of 2% milk and a half-gallon container of organic soy milk that were opened but not labeled with an opened date or… […]

• No harm, potential for more than minimal, widespreadF880Apr 16, 2025

  Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility. Findings include: During a tour of the facility, at 2:38 PM on 4/15/25, it was observed that the hopper in the walk-through Soiled Utility room, in the middle hall, was found with no handles on the faucet and minimal water in the basin of the bowl. This indicates the hopper had not been flushed in a while, once flushed, the basin water raised significantly. […]

• No harm, potential for more than minimal, widespreadF812May 16, 2024

  Based on observation, interview, and record review, the facility failed to discard expired food products, monitor cooling potentially hazardous foods, and properly sanitize dishware, resulting in the potential for increased risk of food borne illness, affecting all residents in the facility that consume food. Findings include: On [DATE] at 11:10 AM, staff were observed to be washing dishes in the dish machine. A plate simulating thermometer was ran through the dish machine to determine the sanitizing final rinse temperature and was found to be 145 degrees F. A second cycle was ran with the thermometer and the internal rinse temperature was 147 degrees F. […]