St. Margaret's Daughters Home

In the surveyor’s words

From the most serious findings on record at St. Margaret's Daughters Home, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF851Dec 18, 2024

  Based on record review, the facility failed to electronically submit payroll information for direct care staffing as required. Findings included: Review of the facility's Payroll Based Journal (PBJ) Staffing Data Report [NAME] Report 1705D Fiscal Year (FY) Quarter 4 2024 (July 1 - September 2024) revealed, in part, the facility failed to submit staffing data for Quarter 4. There was no documented evidence and the facility did not present any documented evidence the facility's PBJ Staffing Data for FY Quarter 4 2024 (July 1 - September 30) was submitted as required.

• No harm, potential for more than minimal, patternF761Jul 23, 2026

  Based on observations, interviews, and record reviews, the facility failed to ensure:1. Expired medication was not available for use (Med Prep Area d, Med Storage Room e); 2. Multi-dose medication containers were labeled with an expiration date to ensure medication was removed from use when the expiration date was exceeded (Med Prep Area b, Med Cart a);3. Medication containers contained the necessary resident identifying information (Med Prep Area c). This deficient practice was identified for 3 (Med Prep Area b, Med Prep Area c, Med Prep Area d) of 4 sampled med prep areas, 1 (Med Storage Room e) of 1 sampled medication storage rooms, and 1 (Med Cart a) of 2 sampled medication carts observed for medication storage requirements. […]

• No harm, potential for more than minimal, patternF689Aug 20, 2025

  Based on observations, interviews, and record reviews, the facility failed to:1. Ensure hazardous chemicals were not accessible to residents (Resident #75's room, Hall c, Hall d, Room f); and, 2. Ensure a resident had sufficient supervision to prevent a fall (Resident #72). This deficient practice was identified for 5 (Resident #75's room, Hall c, Hall d, Room f) of 5 (Resident #75's room, Hall c, Hall d, Room f) locations observed containing unsecured chemicals during observations and for 1 (Resident #72) of 4 (Resident #5, Resident #47, Resident #72, Resident #105) sampled residents investigated for accidents. Findings:1. Observation on 08/18/2025 at 10:26AM revealed a spray bottle with an unknown purple chemical substance on the housekeeper’s cart located on Hall “c”. […]

• No harm, potential for more than minimal, patternF761Aug 20, 2025

  Based on observation and interviews, the facility failed to ensure a medication storage room was not accessible to residents and unauthorized staff for 1 (Medication Storage Room a) of 1 (Medication Storage Room a) medication storage rooms observed during general facility observations. Findings:Observation on 08/18/2025 at 11:03AM revealed the door to Medication Storage Room a was unlocked, and unattended. Further observation revealed medications stored in Medication Storage Room a were accessible to residents and unauthorized staff. In an interview on 08/18/2025 at 11:05AM, S3Licensed Practical Nurse (LPN) confirmed Medication Storage Room a was unlocked, and unattended. S3LPN further indicated she left Medication Storage Room a unlocked. […]

• No harm, potential for more than minimal, patternF812Aug 20, 2025

  Based on observations, interviews, and record review, the facility failed to:1. Ensure the facility's ice machine was maintained in a sanitary manner;2. Ensure food stored in the facility's refrigerator and freezer were properly contained and labeled with an open date; and,3. Ensure dietary staff wore proper hair restraints during food handling and preparation (S10Dietary Aide, S11Dietary Manager).This deficient practice was identified for 2 (S10Dietary Aide, S11Dietary Manager) of 2 (S10Dietary Aide, S11Dietary Manager) dietary staff observed for hair restraints. Findings:1. Observation on 08/18/2025 at 9:19AM revealed pink colored residue located on the inside top corner of the facility's ice machine. […]