Mount St Mary

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF730Mar 31, 2025

  The facility reported a census of 22 residents. Based on interviews and record review, the facility failed to complete an annual performance review at least once every 12 months for Certified Nurse Aide (CNA) M and Certified Medication Aides (CMA) S and CMA T. This placed the residents at risk for decreased quality of care. Findings included: - A review of five employee personnel files, employed by the facility for greater than one year, revealed the following concerns: CNA M, hired on 10/11/23, lacked an annual performance review in her personnel file. CMA S, hired on 12/21/23, lacked an annual performance review in his personnel file. CMA T hired on 1/18/23, lacked an annual performance review in her personnel file. […]

• No harm, potential for more than minimal, widespreadF880Oct 4, 2023

  The facility reported a census of 23 residents. Based on interview and record review, the facility failed to ensure ongoing infection surveillance to determine risks of infections to the residents of the facility. Findings included: - Review of the Infection Control Monthly Logbook, revealed lack of September 2023 log for infections. Interview on 10/04/23 at 08:30 AM, with Administrative Nurse D, revealed the September 2023 log was not completed as staff compiled the logs at the end of the month, not on an ongoing basis to track and trend infections in real time. Administrative Nurse D stated staff discuss infections in Risk Meetings, but actual tracking and trending of infections was done at the end of the month. […]

• No harm, potential for more than minimal, patternF656Oct 4, 2023

  The facility reported a census of 23 residents with 14 residents sampled. Based on observation, interview, and record review, the facility failed to complete a comprehensive care plan for three Residents (R)11, R 15 and R 10, regarding lack of foot pedals on their wheelchairs and R 15, R 4 and R 6, regarding the antipsychotic (used to treat psychosis--any major mental disorder characterized by a gross impairment in reality testing) medication. Findings included: - Review of Resident (R)11's electronic medical record (EMR) revealed diagnoses which included: Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and weakness. […]

• No harm, potential for more than minimal, isolatedF656Mar 31, 2025

  The facility reported a census of 22 residents with 15 residents sampled. Based on interviews and record review, the facility failed to complete a thorough baseline care plan for Resident (R) 17 regarding the use of a non-invasive ventilator (a mechanical ventilation technique that delivers oxygen through a face mask without the use of endotracheal (in the throat) intubation). This placed the resident at risk for respiratory complications due to uncommunicated care needs Findings included: - A review of R17's electronic medical record (EMR) revealed a diagnosis of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). […]

• No harm, potential for more than minimal, isolatedF695Mar 31, 2025

  The facility reported a census of 22 residents with 15 residents sampled, including one resident reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to obtain a physician's order for the use of a non-invasive ventilator (a mechanical ventilation technique that delivers oxygen through a face mask without the use of endotracheal (in the throat) intubation) for Resident (R) 17. This placed R17 at risk for respiratory complications. […]