St Mary Health Care Center

In the surveyor’s words

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

• Actual harm, isolatedF684Oct 29, 2025

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure he/she was provided with quality of care that met professional standards of practice, when he/she did not receive routine laboratory testing to ensure his/her Type 2 Diabetes Mellitus was controlled, when on 09/12/25 he/she experienced a significant change in condition, was found to be hyperglycemic (elevated blood sugar level) with critically high blood sugar reading, he/she required transfer to the Hospital Emergency Department (ED) for evaluation and was admitted for treatment. […]

• Actual harm, isolatedF656Jun 9, 2021

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed as being at risk for falls, required an extensive assist of two staff with transfers and the use of alarms for safety, the Facility failed to ensure staff consistently implemented interventions from his/her comprehensive plan of care, when the position change alarms in his/her room and bathroom, that would have alerted staff that he/she was attempting to ambulate without staff assistance, were not turned on by staff. […]

• Actual harm, isolatedF689Jun 9, 2021

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed for the appropriate use of position change alarms as a fall prevention intervention, the Facility failed to ensure he/she received the necessary assistive devices to maintain his/her safety to prevent an incident/accident with injury. On 5/23/21, Resident #1 had an unwitnessed fall in his/her room, staff found him/her on the floor, he/she complained of lower leg pain, his/her right leg was assessed to be shortened and he/she required emergent transfer to the hospital emergency department, where he/she was diagnosed with an acute moderately displaced right femoral neck fracture (hip fracture). […]

• No harm, potential for more than minimal, widespreadF880Oct 17, 2023

  Based on observations, interviews, and policy and records reviewed, the facility failed to adhere to infection control guidelines to prevent contamination and the potential spread of infection. Specifically, the facility failed to: 1. Ensure that staff doffed (removed) personal protective equipment (PPE) when exiting a COVID-19 positive resident's room; and 2a. Ensure PPE was doffed as required after exiting a COVID positive resident room (Resident #55), and b. that social distancing was maintained for one Resident (#21), who was identified as having COVID-19, and was seated in the Unit Dining Room with other residents who were COVID-19 negative putting the other residents at increased risk for transmission of the virus. Findings include: 44222 1. […]

• No harm, potential for more than minimal, patternF688Apr 14, 2026

  Based on observations, interviews, and record review, the facility failed to provide appropriate assistance for one Resident (#3) out of a total sample of 23 residents, to maintain left-hand range of motion (ROM) when the Resident had a left-hand contracture.Specifically, the facility failed to adequately identify and treat Resident #3's left-hand contracture in a timely manner, when the severity of the Resident's left-hand contracture changed, increasing the Resident's risk for further decrease in ROM and skin breakdown. […]