St Margarets Center

In the surveyor’s words

From the most serious findings on record at St Margarets Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Mar 21, 2022

  Based on observation, record review and interviews during a partial extended abbreviated survey (Case #s NY 829, NY 145 and NY 404), the facility failed to ensure the resident environment remained free of accident hazards as possible and each resident received adequate supervision to prevent accidents, for 4 (Resident #'s 1, 4, 5 and 7) of 7 residents reviewed. Specifically, on [DATE], the facility failed to provide Resident #1 with care planned 1:2 supervision that included tilting the wheelchair back if the resident's head fell forward. The Certified Nurse Aide (CNA) was positioned behind the resident talking on their cell phone and failed to tilt the wheelchair back when the resident's head fell forward. […]

• No harm, potential for more than minimal, patternF758Feb 18, 2025

  Based on records review and interviews during the recertification survey, the facility did not ensure each resident's drug/medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for 10 (Resident #s 1, 6, 10, 45, 46,48, 54, 62, 68, and 79) of 19 residents reviewed for unnecessary medications. Specifically, for Resident #s 1, 6, 10, 45, 46, 48, 54, 62, 68, and 79, as-needed psychotropic medication orders did not include end dates. This is evidenced by: A facility policy titled, Medication Management dated 12/10/2024, documented that as needed orders for psychotropic drugs were limited to 14 days. […]

• No harm, potential for more than minimal, patternF880Feb 18, 2025

  Based on record review and interviews during a recertification survey, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infection. Specifically, the facility water management and sampling plan did not include a simple schematic that visually described the building water system and the identification of areas where Legionella could grow and spread. This is evidenced by: There was no documented evidence that the facility water management and sampling plan included a simple schematic that visually described the building water system and the identification of areas where Legionella could grow and spread. […]

• No harm, potential for more than minimal, patternF695Jun 27, 2023

  Based on record review and interviews during an abbreviated survey (Case #s NY00305353 and NY00316934), the facility did not ensure respiratory care, including tracheostomy care, was provided consistent with professional standards of practice for 7 (Resident #s 6, 7, 8, 9, 10, 11, and 12) of 7 residents reviewed. Specifically, the facility did not consistently provide tracheostomy (surgical procedure to create an opening through the neck into the trachea (windpipe) tube (TT) changes as ordered from August through October 2022 for (Resident #'s 6, 7, 8, 9, 10, and 11). Also, for Resident #s 8 and 9, the facility did not develop and implement a tracheostomy care plan. Care plans were not initiated until 6/15/2023. […]

• No harm, potential for more than minimal, patternF842Jun 29, 2022

  Based on observation, record review and interviews during the recertification survey and an abbreviated survey (Case #NY 015), the facility did not ensure resident records were maintained in accordance with professional standards of practice for 5 (Resident #'s 32, 38, 76, 77, and #280) of 21 residents reviewed. Specifically, for Resident #32, the facility did not ensure staff documented whether the resident was provided with toileting per their assigned toilet training program between 12/1/2021 - 12/15/2021; for Resident #38, the facility did not ensure that the resident's care plan was updated with a new focus, goals, and interventions following a condition change on 6/16/22 when the resident was diagnosed with COVID-19; for Resident #76, the facility did not ensure documentation of… […]