St Marys Home for the Aged

In the surveyor’s words

From the most serious findings on record at St Marys Home for the Aged, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jun 22, 2023

  Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 30 residents residing in the facility. Cold food items were served outside the temperature safe zone and dessert was not covered appropriately during meal service. Hand hygiene was not completed appropriately during lunch service on 6/20/22. Findings include: On 6/21/23 at 1:20 PM, Certified Dietary Manager (CDM)-E stated the facility follows the Wisconsin Food Code. 1. […]

• No harm, potential for more than minimal, widespreadF880Jul 13, 2022

  Based on observations, interviews, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent or contain the transmission of communicable diseases and infections such as COVID-19. This had the potential to affect all 28 resident residing in the facility. Furthermore, based on record review, observations and interviews, the facility did not ensure staff performed proper hand hygiene for 1 Resident (R) (R9) of 3 residents observed during provision of cares. The facility did not require staff to wear N95 respirator into a resident's room who is in quarantine related to COVID-19 precautions. […]

• No harm, potential for more than minimal, patternF880Jun 9, 2021

  Based on observation and staff interview, the facility did not ensure hand hygiene was offered to Residents (R) before meal service for 5 (R14, R33, R34, R35, and R36) of 37 residents at the facility. R14, R33, R34, R35, and R36 were not offered hand hygiene before lunch meal service on 6/7/2021. Findings include: On 6/7/21 beginning at 11:29 AM, Surveyor observed Certified Nursing Assistant (CNA)-G transporting residents to unit dining room. Surveyor observed a container of hand sanitizing wipes on counter of kitchenette but no staff picked up container to offer hand hygiene to residents prior to meal delivery to tables. Surveyor observed R14, R33, R34, and R36 were transported and not offered hand hygiene. R36 was provided full eating assistance by staff. […]

• No harm, potential for more than minimal, isolatedF628Dec 3, 2025

  Based on staff interview and record review, the facility did not ensure reconciliation of discharge medications for 1 resident (R) (R51) of 2 sampled residents. R51 was private pay status and discharged to an Assisted Living (AL) facility on 8/25/25. Medications were not sent with R51 at the time of discharge. The pharmacy was not able to fill all of R51's medications because some were filled by the nursing facility less than 30 days prior. The facility delivered some medications to R51's AL facility on 8/26/25 but did not have a record of which medications were delivered. R51 missed three doses of a Parkinson's medication.Findings include:The facility's Discharge Planning policy, revised 3/31/17, indicates: .5. Implement Discharge Plan: .f. […]

• No harm, potential for more than minimal, isolatedF658Dec 3, 2025

  Based on staff and resident representative interview and record review, the facility did not ensure a new diagnosis of schizophrenia met clinical criteria for 1 resident (R) (R1) of 1 sampled resident.R1 was admitted to the facility on [DATE]. On 6/6/25, R1 received a new diagnosis of schizophrenia. The facility did not have evidence that R1's diagnosis met the diagnostic criteria in The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Findings includeAccording to The American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (a resource used by mental health professionals to diagnose mental disorders), to meet the criteria for a diagnosis of schizophrenia, the patient must have experienced two (or… […]