Mary Wade Home

In the surveyor’s words

From the most serious findings on record at Mary Wade Home, in the surveyor’s own words.

• Actual harm, isolatedF689Nov 1, 2023

  Based on a review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #2), reviewed for falls, the facility failed to protect the resident's safety during care resulting in a fall out of bed and the resident sustained a laceration to the head that required staples. The finding includes: Resident #2 was admitted to the facility with diagnoses that included dementia, anxiety and protein calorie malnutrition. A physician's order dated 6/10/21 directed two half side rails up to promote bed mobility. Review of the fall risk assessment dated [DATE] identified Resident #2 was a high risk for falls. […]

• No harm, potential for more than minimal, widespreadF603Feb 25, 2025

  Based on observations, review of the clinical records, facility documentation, facility policy and interviews for 2 of 2 nursing units, the facility failed to ensure residents who did not meet clinical criteria to reside on a locked unit were provided with a method of opening doors independently. The findings include: Observations on 2/11/2025, 2/13/2025, 2/18/2025, 2/19/2025, 2/20/2025, 2/21/2025, 2/24/2025 and 2/25/2025 identified both nursing units: first floor (unit K1) and second floor (unit K2), had secured doors for entering and exiting the units to both stairwells and the elevator. A number code entered into a keypad was required to open the doors. […]

• No harm, potential for more than minimal, widespreadF812Feb 25, 2025

  Based on the tour of the Dietary Department, observations, staff interview, facility documentation and facility policy, the facility failed to ensure the Dietary Department served food at temperatures outside of the danger zone and failed to maintain dishwasher hot water temperatures at or above 160 degrees Fahrenheit. The findings included: 1. Observation of the tray line on 2/18/2025 at 12:49 PM identified a test tray was placed on the last meal delivery cart which was brought to the first floor. The meal delivery cart lacked doors and resembled a commercial sheet pan rack. The meal plates were covered with hard plastic covers and did not contain warming pellets. The test tray was the last tray served on the first floor. […]

• No harm, potential for more than minimal, patternF730Feb 25, 2025

  Based on facility documentation, facility policy and interviews for 4 of 6 employee files, the facility failed to ensure the required annual performance evaluations were completed. The findings include: 1. NA #3's date of hire was 10/19/21. No performance evaluation was identified in the employee's personnel file. Although requested, the facility could not provide annual evaluations for NA #3. 2. NA #4's date of hire was 6/6/18. No performance evaluation was identified in the employee's personnel file. Although requested, the facility could not provide annual evaluations for NA #4. 3. NA #5's date of hire was 10/20/21. No performance evaluation was identified in the employee's personnel file. Although requested, the facility could not provide annual evaluations for NA #5. 4. […]

• No harm, potential for more than minimal, patternF761Feb 25, 2025

  Based on observations, interviews, and facility policy for 2 of 2 medication rooms reviewed for medication storage and lebeling, the facility failed to date 3 of 3 multi dose Tuberculin PPD vials upon opening. The findings included: During a review of the facility medication storage rooms on 2/13/25 at 10:17 AM, the following was identified: a. On the K1 unit a vial of Tuberculin PPD was stored in the refrigerator. The vial was noted to have been opened, was half full, without the benefit of being dated. b. On the K1 unit a vial of Tuberculin PPD was stored in the refrigerator. The vial was noted to have been opened, and was slightly more than half full, without the benefit of being dated. c. On the K2 unit a vial of Tuberculin PPD was stored in the refrigerator. […]