St. Mary's Hospital

Inspectors wroteBased on document review and staff interview, the facility failed to check the nurse-aide registry when ancillary are first hired. This was true for 2 of 2 ancillary staff. Facility census 13.a) On 04/14/2026 at approximately 1:10 p.m., there was no documentation readily available for Maintenance Tech #45 and Housekeeper #46 that the employees were checked on the Nurse Aide registry. b) On 04/14/26 at approximately 1:13 PM, conducted an interview with the HR Generalist and Educator (Employee #44) for the unit. Employee #44 stated that they do not check the Nurse Aide registry with ancillary staff (Maintenance Tech #45 and Housekeeper #46). The deficiency was verified with the HR Generalist and Educator along with unit Clinical Manager. c) On 04/15/26 at approximately 2:30 p.m., the deficiency was acknowledged by the unit's Administrative staff upon the exit interview.

Inspectors wroteBased on record review, review of skilled nursing unit's NA Role Profile Summary, and staff interview, the facility failed to ensure the staff had the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs. This was true for four (4) of seven (7) nursing staff reviewed for competenencies. Staff Identifiers: NA #12, #45, #2, and #13. Facility census: 12.

Inspectors wroteBased upon observation and staff interview, the facility failed to properly store pre-cooked breakfast sausage links by not providing an expiration date after opening and removing the product from its original packaging. This had the potential to affect residents of the facility who might consume this breakfast sausage. Facility census: 12.

Inspectors wroteBased upon record review and staff interview, the facility failed to provide twelve (12) hours of in-service training for nurse aides to include dementia, or specific care to the unit's resident population This was true for five (5) of five (5) Nurse Aides (NAs) reviewed. Staff identifiers: NA #3, #12, #45, #2, #13. Facility census: 12.

Inspectors wroteBased on observations and staff interview, the facility failed to provide a clean, comfortable home like environment by having debris in the return vents in Resident's #109 room and Resident's #108 room and bathroom. This was a random opportunity for discovery during the long term care survey process. Resident identifier: #108 and #109. Facility census: 12.

Inspectors wroteBased on record review and staff interview, the facility failed to complete the WV Cares report prior to new staff reporting to work. This was found to be true for three (3) of eight (8) staff files reviewed. Staff identifiers: #37, #3, and #12. Facility census: 12.

Inspectors wroteBased on record review and staff interview, the facility failed to develop a care plan for pain for Resident #3. This failed practice was found true for one (1) of eight (8) care plans reviewed during the Long-Term Care Survey Process. Resident Identifier:

Inspectors wroteBased upon record review, observation, staff interview, and interview with a visitor, the facility failed to ensure daily nurse staffing information was readily available in a format that was clear and readable as found during the staffing review of the long term care survey process. Facility census:

Inspectors wroteBased on observation, record review and staff interview, the facility failed to dispose of expired single-serve condiments stored in the resident refrigerator in the unit pantry. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility Census: 9. Findings Included: a) Resident Refrigerator On [DATE] at 11:10 AM, a tour of the unit pantry was completed. The tour found the resident refrigerator containing multiple expired single-serve packets of condiments. The expiration dates found were [DATE] on the salad dressings and [DATE] for the tartar sauces. b) Facility Policy A review of the facility policy entitled Maintaining Kitchenettes dated 08/2021 II D h. states, Do not keep patient silverware or condiments from the trays on the unit. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to provide Peripherally Inserted Central Catheter (PICC line) care in accordance with professional standards of practice. This deficient practice had the potential to affect one (1) of one (1) residents receiving intravenous (IV) antibiotics. Resident identifier: #57. Facility census: 9.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain appropriate infection control standards for the storage of clean linen. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents at the facility. Facility Census: 9. Findings Included: On 01/15/24 at 1:02 PM, the resident bath/shower room was toured. The tour found folded clean towels uncovered laying on the dirty linen cart lid and on the top of the biohazard box sitting in the floor. On 01/15/24 at 1:04 PM, Registered Nurse (RN) #13 was notified. RN #13 stated, those aren't supposed to be there .I'll take care of it. On 01/15/24 at 1:20 PM, the Clinical Manager (CM) #18 was notified and confirmed the clean linen should not be stored in the resident bath/shower room. No further information was obtained during the survey process.

Inspectors wroteBased on record review and staff interview, the facility failed to obtain proper consent or declination for a COVID-19 booster. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of immunizations. Resident identifier: #57. Facility census: 9.