St. Mary's Nursing Center Inc

Inspectors wroteBased on administrative review and interviews with facility staff it was determined the facility failed to ensure staff reported allegations of abuse timely after bruising of unknown origin on a resident was discovered This was found to be evident in 1(#74) of 6 residents' facility reported incidents reviewed during the annual Medicare/Medicaid survey.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medications were administered as ordered by the physician and according to accepted standards of nursing practice, including administering medications at the correct time. This was evident for 3 (#127, #58, #128) of 4 residents observed and reviewed for medication administration. According to accepted standards of nursing practice, including the patient medication rights outlined in the Maryland Nurse Practice Act, medications must be administered according to the right time, meaning medications should be administered at the time intended by the prescriber to maintain therapeutic effectiveness. The Findings Include: 1. A medication administration observation was conducted on 03/10/2026 at 10:05 AM for Resident #127. [...]

Inspectors wroteBased on observation and staff interview it was determined the facility failed to ensure safe medication administration and proper assessment for self-administration. This was evident for 1 (#110) of 4 residents reviewed for medication administration.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure a medication was clinically indicated and evaluated for continued need. This occurred for 1 (#32) of 5 residents reviewed for unnecessary medications during the annual survey.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure the facility was in good repair. This was evident for 5 resident rooms observed on the 4th floor nursing unit during the survey.

Inspectors wroteBased on observations and interviews with facility staff, it was determined that the facility failed to ensure residents were treated with respect and dignity when requesting assistance and by failing to ensure a Foley drainage bag was covered. This was found to be evident for 2 out of 40 (Resident #47 and Resident #461) sampled residents reviewed during the survey.

Inspectors wroteBased on record review and interview with staff it was determined that the facility failed to ensure a resident was offered the opportunity to participate in their care planning process by being invited to their care plan meetings. This was evident for 2 (Resident #12 and #31) out of 4 residents investigated for care planning during the survey.

Inspectors wroteBased on complaint, review of medical records, and staff interview, it was determined that the facility failed to transcribe a physician's order that directed nurses to obtain a wound care consult for a resident. This was evident for 1 (Resident #313) out of 40 sampled residents reviewed during the survey.

Inspectors wroteBased on observation, record review, and interviews, it was determined that the facility failed to ensure: 1) a resident's safety was maintained during a transfer. This was evident for 1 of 2 residents (Resident #6) reviewed for accidents and 2) an order for seizure precautions on a resident were correctly maintained. This was evident for 1 of 2 residents (Resident #21) reviewed for position and mobility.

Inspectors wroteBased on observation, interview, and documentation review it was determined that the facility staff failed to ensure the walk-in refrigerator temperatures were documented accurately.

Inspectors wroteBased on medical record review and interview, the facility failed provide adequate notice to a resident (resident #1) prior to discharge. This was evident in 1 of 5 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility failed prepare a resident (resident #1) for discharge. This was evident in 1 of 5 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility failed to allow a resident (resident #1) to return to the facility after transfer for emergency treatment. This was evident in 1 of 5 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility's administration failed to provide leadership to facility staff to ensure CMS regulations are being followed when involuntarily discharging a resident (resident #1). This was evident in 1 of 5 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility failed to document the discharge of a resident (resident #1). This was evident in 1 of 5 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review, observation and staff interview, it was determined facility staff failed to ensure that comprehensive person-centered care plans with measurable goals were developed 1) for participation in activities that enhance resident's quality of life for Residents #123, #125 and #35; and 2) for Resident #68 who used a lap buddy. This was evident for 4 of 50 residents whose care plans were reviewed during the survey.

Inspectors wroteBased on observation and staff interviews it was determined that the facility staff failed to ensure that food was stored and prepared in sanitary manner. This practice has a potential of effecting all residents in facility.

Inspectors wroteBased on observation, staff interview and review of medical records and other pertinent documentation, it was determined a nursing staff member failed to ensure adequate supervision was provided to Resident #198 when assisting him/her to stand. This was evident for 1 of 40 residents reviewed for falls during the survey.

Inspectors wroteBased on observation, review of pertinent documentation and staff interview it was determined the facility failed to ensure a nursing staff member washed her hands appropriately after passing medications to Residents #46 and #7. This was evident for 2 of 4 times nursing staff were observed for handwashing.

Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility failed to ensure survey results from the most recent Federal survey were readily accessible to residents without having to ask staff. This practice had the potential to affect all residents.