St Martha Center for Rehabilitation & Healthcare

In the surveyor’s words

From the most serious findings on record at St Martha Center for Rehabilitation & Healthcare, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF802Aug 29, 2023

  Based on resident and staff interviews, observations, and facility documentation review it was determined the facility failed to have adequate number of dietary staff to meet the needs of the residents. Findings Include: Interviews conducted with Resident R1, R2, R3, R4, and R5 on August 29, 2023 between 9:15 and 9:50 a.m. revealed the breakfast trays are always late for the residents and arrive between 9:15 a.m. and 10:15 a.m. Observations of the breakfast tray delivery on August 29, 2023 revealed the last tray was delivered to a resident on the 600 hall at 10:10 a.m. Observation of the dining room during the breakfast meal revealed the dining room was not being used and a sign was posted to the door that it opens at 8:15 a.m. […]

• No harm, potential for more than minimal, widespreadF812Mar 18, 2021

  Based on observations, facility policy review, and staff interview it was determined the facility failed to ensure sanitizer concentrations were at an effective level in the kitchen. Findings Include: Review of facility policy and procedure titled, Department Sanitation, dated November 30, 2017, revealed Food and Nutrition staff maintain the sanitation of department by ensuring that sanitizing bucket solutions are at an appropriate concentration and are changed frequently throughout the day. Review of the manufacturer label for Santec disinfectant-sanitizer revealed when used as directed this product is an effective sanitizer at an active quaternary concentration (QAC-a cleaner and sanitizer for various food surfaces) of 200-400 ppm (parts per million) when diluted in water. […]

• No harm, potential for more than minimal, patternF692Jan 12, 2024

  Based on clinical record review, facility policy and procedure review, and staff interview it was determined the facility failed to obtain weights to maintain residents' nutritional status for four of 14 residents reviewed. (Residents 26, 74, 109, and 113) Findings Include: Review of facility policy and procedure titled Resident Weights, revised May 2022, revealed the nursing staff will measure residents' weights during the admission process which can take up to 24 to 48 hours from admitted . If no weight concerns are noted at this point, weights will be measured monthly thereafter. Weights will be recorded in each resident electronic medical record. Any weight change of 5% or more since the last weight assessment will be retaken. […]

• No harm, potential for more than minimal, patternF804Mar 10, 2023

  Based on a review of facility documentation, observation, and staff interview it was determined that the facility failed to provide foods that were served at the proper temperature to ensure resident satisfaction on one of two units (Garden). Findings include: Review of the facility's policy titled Meal assessments, dated November 28, 2017, revealed that foods are served at temperatures appropriate for food safety and palatability. Review of the facility's documentation, Tray Assessments revealed that the standard temperature at the point of service is 140 F min.(minimum) for starch, vegetables, and entree. […]

• No harm, potential for more than minimal, patternF730Mar 18, 2021

  Based on a review of employee personnel records and staff interview, it was determined that the facility failed to complete performance reviews for four of five nurse aides reviewed (Employee E14, E15, E16, and E17). Findings Include: A list of nurse aides provided by the facility failed to reveal that the following employees had an annual performance review completed by the facility: Employee E14 (Date of Hire-September 3, 2009), Employee E15 (Date of Hire - September 3, 2009), Employee E16 (Date of Hire- August 17, 2006), and Employee E17 (Date of Hire-March 5, 2004). An interview with the Director of Nursing on March 18, 2021, at 1:00 p.m., confirmed that the annual performance review of the above employees was not conducted in the year 2020. […]