Mary, Queen and Mother Center

In the surveyor’s words

From the most serious findings on record at Mary, Queen and Mother Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Mar 24, 2025

  52419 Based on observation, interview and record review, the facility failed to maintain an environment free of accident hazards by not maintaining water temperatures in resident rooms on the [NAME] Hall in the [NAME] community between 105 degrees Fahrenheit (F) and 120 F. The [NAME] hall and [NAME] Hall are both parts of the dementia unit. The facility identified three residents with confusion, who wander and who are able to ambulate without assistance (Residents #74, #26, and #13). This affected two sampled resident rooms (Residents #40 and #85) and one spa room hand washing sink . The water temperatures at the handwashing sinks measured as high as 135.9 degrees F. In addition, staff failed to ensure hazardous chemicals were not accessible to residents on the dementia unit. […]

• Immediate jeopardy, isolatedF600Dec 6, 2022

  Based on interview and record review, the facility failed to ensure one resident was free from employee to resident abuse in which a resident's spouse restrained the resident while an agency nurse forced a syringe of medication into the resident's closed mouth, despite his/her verbal protests and physical resistance, for one of three sampled residents (Resident #4). The census was 121. The administrator was informed on 11/28/22 of an Immediate Jeopardy (IJ), which began on 10/16/22. […]

• No harm, potential for more than minimal, widespreadF804Oct 18, 2021

  Based on observation, interview and record review, the facility failed to ensure food was served palatable and at a safe and appetizing temperature during meal service by failing to maintain the temperature of hot food at least at 120 degrees Fahrenheit (F) for two of two meals sampled. The census was 128. 1. During an interview on 10/13/21 at 12:07 P.M., three of six residents in the rehab dining area said on a scale from one to ten, the food is rated a five and is often luke warm. 2. […]

• No harm, potential for more than minimal, patternF919Dec 19, 2025

  Based on observation, interview and record review, the facility failed to maintain its call light system in working order and according to the stipulations in the state exception granted to them, allowing use of the current call light system. This deficiency had the potential to affect all residents and affected one sampled resident who had a toe injury (Resident#1). The sample size was four. The census was 74. Review of the facility's call light policy dated 6/9/17, showed:It is the policy of the facility to provide quality long-term care to residents. All residents will have a call light within reach while in bed or sitting next to the bed.Answering call lights is the responsibility of all Nursing Staff members with priority given to bathroom call lights. […]

• No harm, potential for more than minimal, patternF727Jan 8, 2024

  Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week during the fiscal year quarter 4 2023 (July 1 - September 30). The census was 106 with 103 residents in certified beds. The administrator was notified on 1/8/24, of the past non-compliance. The facility has contracted for RN agency staff to cover for days where no facility employed RN was available. The deficiency was corrected on 10/1/23. […]