St Mary's Center Inc

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF584Feb 12, 2025

  Based on observation, record review, and interview during the Recertification Survey conducted from 02/05/2025 to 02/12/2025, the facility did not ensure that residents' right to a safe, clean, comfortable, and homelike environment was provided. This was evident in 3 of 4 units (Units 2, 3, and 5). Specifically, rooms were not cleaned, window screens were torn, windowsills were layered with dust, floor corners were embedded with in dirt, resident furniture in disrepair, resident equipment were not cleaned, and there was leak in the ceiling. The findings include but are not limited to: The facility was not able to provide a policy for environmental services. During multiple observations from 02/05/2025 through 02/12/25, the following were observed: 1. […]

• No harm, potential for more than minimal, isolatedF761Feb 12, 2025

  Based on observation, record review, and interview during the Recertification Survey conducted from 02/05/2025 to 02/12/2025, the facility did not ensure that the storage for controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 were safe and secure. This was evident in 1 of 4 units during the Medication Storage Task. Specifically, the Narcotic Box in Unit 2 was not properly secured. The findings are: The facility policy titled Medication Storage with a revised date of 02/2025 documented Scheduled II - V medications must be maintained in a separately locked, permanently affixed compartments or cabinets. During an observation on 02/05/2025 at 10:18 AM in Unit 2, the Medication Room located inside the nurse station was inspected. […]

• No harm, potential for more than minimal, isolatedF656Sep 27, 2023

  Based on observation, interviews, and record review conducted during the recertification survey from 9/20/2023 to 9/27/2023, the facility did not ensure that a comprehensive, person-centered care plan (CCP) was developed for each resident. This was evident for 1 (Resident #29) of 15 total sampled residents. Specifically, a CCP related to infection was not developed for Resident #29 who had an active diagnosis of urinary tract infection (UTI). The findings are: Resident #29 had diagnoses of UTI and schizophrenia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #29 was cognitively intact. On 09/21/23 at 12:12 PM, Resident #29 was interviewed and stated they have burning upon urination and are receiving an antibiotic. […]

• No harm, potential for more than minimal, isolatedF695Sep 27, 2023

  Based on observation, record review, and interviews conducted during the Recertification Survey from 9/20/23 through 9/27/23, the facility did not ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice. This was evident for 1 out of 2 residents reviewed for respiratory care out of 15 sampled residents (Resident # 87). Specifically, 1) Resident # 87 was observed using oxygen via the Nasal Cannula (NC) at 4 liters while the Medical Doctor's Order (MDO) documented 2 liters, and 2) There was no dated label on the oxygen tube. […]

• No harm, potential for more than minimal, isolatedF842Sep 27, 2023

  Based on observation, record review, and interviews conducted during the Recertification Survey from 9/20/23 through 9/27/23, the facility did not ensure that the resident records were accurately documented in accordance with professional standards of practice. Specifically, Registered Nurse #3 (RN #3) signed for a 7:00 AM dose of Suboxone while the Suboxone was left in the medication cart. This was evident in 1 out of 8 residents reviewed for medication administration. (Resident #27). The findings are: The facility policy and procedure titled Medication Administration with last revised date 9/7/23 documented that it is the facility's policy to ensure that all residents are taking medications in a safe manner in accordance with physician's order. […]