Senior Care Center - St Marys

In the surveyor’s words

From the most serious findings on record at Senior Care Center - St Marys, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812May 13, 2026

  Based on observations, staff interviews, and review of the facility's policies titled, Foodborne Illnesses, and Food Ordering, Receiving, and Storage, the facility failed to ensure food for residents was stored, prepared, and served in a sanitary manner in the kitchen. Specifically, the facility failed to label and date food in the freezer, the refrigerator/walk-in cooler, and the dry storage pantry, with a received by date, open date, expiration, and/or use-by date, failed to discard food by the expiration or use-by date, and failed to ensure meat was thawed properly and in a sanitary manner. […]

• No harm, potential for more than minimal, widespreadF812Mar 14, 2024

  Based on observation, staff interview, and review of the facility policy titled, Food and Supply Storage, the facility failed to ensure all pans and dishes were allowed to be air dried before stacked and failed to ensure all food in the freezer was sealed closed. These failures had the potential to affect 63 of 65 residents who consumed an oral diet. Findings include: Review of the facility's policy titled, Food and Supply Storage, dated 1/2024 revealed, All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Frozen storage: Wrap food tightly to prevent cross contamination. […]

• No harm, potential for more than minimal, widespreadF867Mar 14, 2024

  Based on staff interview, facility document review, and review of the facility policy titled, Quality Assurance/Performance Improvement, the facility staff failed to maintain an effective Quality Assurance/Performance Improvement (QAPI) program regarding the facility's Performance Improvement Plan (PIP) for Certified Nursing Assistants (CNAs) documentation. This had the potential to affect all residents of the facility. Findings include: Review of the facility policy titled, Quality Assurance/Performance Improvement (undated) revealed, .The facility will implement the Plan-do-Study-Act (PDSA) cycles as its QAPI methodology for testing actions and implementing and evaluating change. The facility will conduct and include Root Cause Analysis in their PDSA methodology. […]

• No harm, potential for more than minimal, widespreadF881Mar 14, 2024

  Based on staff interviews, document review, review of Centers for Disease Control and Prevention (CDC) guidance, and review of the facility policy titled, Antibiotic Ordering, the facility failed to maintain an infection prevention and control program (IPCP) that included a functional Antibiotic Stewardship Program that followed the McGeer Criteria for antibiotics. This had the potential to affect all 65 resident of the facility, specifically being prescribed antibiotics that were potentially unnecessary. Findings include: Review of the facility policy titled, Antibiotic Ordering dated 9/01/2023 revealed . 10. The Infection Control Preventionist (lCP) will monitor resident antibiotic use to determine appropriateness.11. […]

• No harm, potential for more than minimal, widespreadF880Jun 30, 2022

  Based on observation, interviews, record review, and review of facility policy titled Infection Prevention and Control Program Overview the facility failed to maintain an effective infection prevention and control program that demonstrated ongoing surveillance, recognition, investigation, and control of infection to prevent the onset and spread of infection. The facility census was 53. Findings include: Review of facility's undated policy titled Infection Prevention and Control Program Overview 5. The facility will ensure the following elements are incorporated within the IPCP management activities. […]