St Mary Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF888Jun 7, 2022

  Based on interview and record review, the facility failed to ensure 100% of their staff were fully vaccinated, when 4 of 5 partially vaccinated staff members did not complete their second Covid-19 vaccination as required for the vaccine mandate. (CRCA 1, RCA 2, CRCA 3 and Payroll staff 4). In the last 4 weeks, the facility had 26 positive residents, three hospitalized and four deaths. (Residents E, F, G and H). The immediate jeopardy began on [DATE], when Resident Care Assistant (RCA 2) should have received the second Covid-19 vaccination after having the first Covid-19 vaccination on [DATE]. Certified Resident Care Assistant (CRCA) 1 received the first Covid-19 vaccination on [DATE] and was due for the second vaccine on [DATE]. […]

• Actual harm, isolatedF692Jan 24, 2022

  Based on interview and record review, the facility failed to timely identify a significant weight loss, to timely implement interventions for the significant weight loss and to prevent further weight loss for a cognitively impaired resident for 1 of 3 residents reviewed for nutrition (Resident E). Resident E had a significant weight loss of 11.01% in 31 days. Finding includes: During a dining observation, on 1/21/2022 at 5:17 p.m., 21 residents were in the dementia dining room. Resident E was in her room, laying on the bed with her eyes closed and the room darkened. There was a tray on the bedside table across the room and the food had not been unwrapped yet. During an observation, on 1/21/2022 at 5:31 p.m., Resident E was still laying in her bed and the room was darkened. […]

• Actual harm, isolatedF760Jan 24, 2022

  Based on record review and interview, the facility failed to administer an anticoagulant as ordered and failed to hold an anticoagulant as ordered for 1 of 3 residents reviewed for unnecessary medication (Resident D). Resident D had to receive an antidote of vitamin K due to elevated lab results and increased bruising. Finding includes: 1. The record for Resident D was reviewed on 1/21/22 at 2:53 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 12/14/21, indicated the resident was at a risk for excessive bleeding and bruising related to medication. […]

• No harm, potential for more than minimal, widespreadF812Mar 31, 2026

  Based on observation, interview and record review, the facility failed to ensure the food preparation area did not contain employee drinks and frozen food was sealed in 1 of 1 kitchen reviewed. This deficient practice had the potential to affect 65 of 65 residents who received food from the kitchen.Findings include:During the kitchen observation, on 3/24/26 at 9:36 a.m., with the Dietary Manager, the following were observed:a. The food preparation counter had two unopened cans of energy drinks and a white cup with a lid and straw stored next to a jar of peanut butter and loaf of bread.b. On the second shelf in the walk-in freezer, there was a large opened plastic bag containing one skinless chicken breast. The chicken breast had a small amount of ice buildup on the upper left corner.c. […]

• No harm, potential for more than minimal, patternF550May 19, 2025

  Based on observation, interview and record review, the facility failed to ensure residents were served their meals together, staff were seated while eating with the residents, and a resident was able to complete their meal before being removed from the dining room for 1 of 2 dining rooms reviewed for dignity. (the legacy dining room) Findings include: 1. During an observation, on 5/14/25 at 12:00 p.m., the residents were seated in the legacy dining room. CNA 15 took a resident's meal ticket, gave the ticket to Dining Assistant 12, and he prepared the resident's plate. The CNAs passed out plates to residents seated at different tables randomly until all residents were served. […]