St Mary of the Woods

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF812Aug 28, 2025

  Based on observation, policy review, and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect 32 out of 36 residents who ate meals in the facility's kitchen. Four residents (Residents #1, #4, #10 and #24) received enteral nutrition and did not receive meals from the kitchen. The facility census was 36. Observations during the initial tour of the kitchen on 08/25/25 from 10:27 A.M. through 10:50 A.M. revealed the wall behind the grill and stove had grease built-up with food spattered, the deep [NAME] shield on the side of the deep [NAME] had half inch thick grease built up. The hood screens above the grill and stove had heavy grease buildup and the stove had burnt food and flood splatter all over it. […]

• No harm, potential for more than minimal, isolatedF880Aug 13, 2026

  Based on medical record review, observation, interviews, facility policy review, and review of the Centers for Disease Control (CDC) guidelines, the facility failed to implement and/or maintain appropriate transmission-based and enhanced barrier precautions. This affected two residents (Residents #6 and #7) of two residents reviewed for infection control precautions. The facility census was 50.Findings include: 1. Review of the medical record for Resident #7 revealed he was admitted to the facility on [DATE] with diagnoses that included zoster ocular disease, herpes viral ocular disease, and cerebral infarction. […]

• No harm, potential for more than minimal, isolatedF684Jun 1, 2026

  Based on record review, observation, facility policy review, and interview, the facility failed to ensure staff followed physician orders when administering Resident #26's and Resident #44's respiratory aerosol treatments. This affected two residents (#26 and #44) out of three residents reviewed for respiratory care. The facility census was 43. Findings include:1. A review of Resident #44's clinical record revealed an admission date of 02/18/26 with diagnoses including chronic obstructive pulmonary disease, emphysema, high blood pressure and cholesterol, atherosclerotic heart disease, esophagitis, peripheral vascular disease, stage IV chronic kidney disease, hyperparathyroidism secondary to renal origin, radiculopathy (spinal nerve compression), cataract, malaise, pupillary abnormality,… […]

• No harm, potential for more than minimal, isolatedF583Aug 28, 2025

  Based on medical record review, interviews, and review of facility policy, the facility failed to ensure the resident personal privacy and confidentiality of medical records was maintained. This affected one resident (#63) of two residents reviewed for medical record release. The facility census was 36. Findings include: Interview with Resident #58's Family Member (FM) on 08/27/25 at 1:32 P.M. revealed she received Resident #58's medical records as requested from the facility, however; it also included another Resident's (#63) personal information, date of birth , insurance, diagnoses, and complete care plan. […]

• No harm, potential for more than minimal, isolatedF695Aug 28, 2025

  Based on record review, staff interviews, and facility policy, the facility failed to provide necessary respiratory care and services in accordance with professional standards of practice and facility policy. This affected one resident (#58) of three residents reviewed for oxygen administration. The facility census was 36.Review of medical record for Resident #58 revealed an admission date of 04/01/25 with diagnoses of acute respiratory failure with hypoxia, Parkinson's disease, heart failure with ejection fraction of 42%, dysphagia, history of falls, hypertension, myocardial infarction, and cognitive deficits.Review of the Minimum Data Set (MDS) assessment for Resident #58 dated 04/04/25 revealed the resident had cognitive decline as evidenced by a Brief Interview for Mental Status (BIMS)… […]