St Mary's Alzheimer's Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF583Dec 11, 2024

  Based on record review, review of a facility self-reported incident (SRI), review of a social media post, review of the facility's policies on personal cell phone use and social media, and interviews the facility failed to protect the privacy of Resident #28 during personal care. This resulted in Immediate Jeopardy on 11/27/24 when Certified Nursing Assistant (CNA) #500 made a cell phone recording of Resident #28, who was observed in the video slouched in a shower chair with her pants around her ankles and her shirt pulled up above her breasts exposing her bare body from her breasts down to just above her ankles. There was a large amount of fecal matter on the floor under Resident #28 and the video panned around the shower room to show more fecal matter in another area of the room. […]

• Immediate jeopardy, isolatedF600Dec 11, 2024

  Based on observation, record review, review of a facility self-reported incident (SRI), review of a social media post, review of the facility's policies on personal cell phone use, social media, and abuse, and interview, the facility failed to ensure Resident #28, who was assessed to be cognitively impaired, was free from staff to resident mental/emotional abuse when Certified Nursing Assistant (CNA) #500 took a video of Resident #28 during personal care on her personal cell phone and posted the video to the social media platform Snapchat. […]

• Immediate jeopardy, isolatedF607Dec 11, 2024

  Based on observation, record review, review of a facility self-reported incident (SRI), review of a social media post, review of the facility's policies on personal cell phone use, social media, and abuse, and interview, the facility failed to effectively implement their abuse policy to prevent staff to resident abuse and to appropriately recognize the incident as abuse. This resulted in Immediate Jeopardy on 11/27/24 when Certified Nursing Assistant (CNA) #500 took a video of Resident #28 during personal care, in which the resident's bare body was from her breasts down to just above the ankles with a substantial amount of fecal matter on the floor around the resident, on her personal cell phone and posted the video to the social media platform Snapchat with a text overlay that read bruh… […]

• No harm, potential for more than minimal, patternF880Mar 26, 2026

  Based on observation, record review, interview, and facility policy review, the facility failed to ensure infection control practices were implemented correctly. This affected five Residents (#10, #12, #29, #56, and #82) of seven reviewed for infection control, and had the potential to affect 37 residents who resided on the south hall or who were observed for medication administration. The facility census was 75.Findings include:1.Review of the medical record for Resident #82 revealed an admission date of 03/20/26. Diagnoses included urinary tract infection (UTI), dementia, hypertension and heart failure. The comprehensive minimum data set (MDS) assessment was not yet completed at the time of the survey. […]

• No harm, potential for more than minimal, patternF921Oct 24, 2024

  Based on observation, staff interviews, review of safety data sheets, and review of the facility policy, the facility failed to ensure harmful cleaning chemicals were not accessible to severely cognitively impaired residents. This had the potential to affect 36 residents (#1, #7, #8,#11, #13, #12, #14, #19, #20, #21, #22, #25, #26, #34, #35, #39, #40, #41, #44, #45, #47, #49, #51, #52, #54, #58, #59, #60, #63, #64, #65, #67, #69, #74, #76, #180) identified by the facility as being both mobile and severely impaired cognitively. The facility census was 76. Findings include: Observation on 10/23/24 from 10:53 A.M. to 10:57 A.M. […]