St. Mary's Hospital

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF606Apr 15, 2026

  Based on document review and staff interview, the facility failed to check the nurse-aide registry when ancillary are first hired. This was true for 2 of 2 ancillary staff. Facility census 13.a) On 04/14/2026 at approximately 1:10 p.m., there was no documentation readily available for Maintenance Tech #45 and Housekeeper #46 that the employees were checked on the Nurse Aide registry. b) On 04/14/26 at approximately 1:13 PM, conducted an interview with the HR Generalist and Educator (Employee #44) for the unit. Employee #44 stated that they do not check the Nurse Aide registry with ancillary staff (Maintenance Tech #45 and Housekeeper #46). The deficiency was verified with the HR Generalist and Educator along with unit Clinical Manager. […]

• No harm, potential for more than minimal, patternF726Feb 26, 2025

  Based on record review, review of skilled nursing unit's NA Role Profile Summary, and staff interview, the facility failed to ensure the staff had the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs. This was true for four (4) of seven (7) nursing staff reviewed for competenencies. Staff Identifiers: NA #12, #45, #2, and #13. Facility census: 12. Findings included: a) NA Role Profile Summary: NA Role Profile Summary dated 01/10/18 revealed HSAF.-16015 Personal Protective Equipment Demonstrates appropriate selection of personal protective equipment (PPE). […]

• No harm, potential for more than minimal, patternF812Feb 26, 2025

  Based upon observation and staff interview, the facility failed to properly store pre-cooked breakfast sausage links by not providing an expiration date after opening and removing the product from its original packaging. This had the potential to affect residents of the facility who might consume this breakfast sausage. Facility census: 12. Findings included: During observation of the kitchen freezers and refrigerators on 02/25/25 around 11:00 AM, a partial bag of opened, pre-cooked breakfast sausage links was found on the top shelf of a cart in one of the walk-in refrigerators. The bag contained no expiration date. When this was pointed out to the Dietary Director, he immediately threw the bag into the trash.

• No harm, potential for more than minimal, patternF947Feb 26, 2025

  Based upon record review and staff interview, the facility failed to provide twelve (12) hours of in-service training for nurse aides to include dementia, or specific care to the unit's resident population This was true for five (5) of five (5) Nurse Aides (NAs) reviewed. Staff identifiers: NA #3, #12, #45, #2, #13. Facility census: 12. Findings included: a) NA #3: Education report showed a total of 5 hours of education for 2024, and did not contain education on dementia care. b) NA #12: Education report showed a total of < 5 hours of education for 2024, and did not contain education on dementia care. c) NA #45 Education report showed a total of < 5 hours of education for 2024, and did not contain education on dementia care. […]

• No harm, potential for more than minimal, patternF812Jan 17, 2024

  Based on observation, record review and staff interview, the facility failed to dispose of expired single-serve condiments stored in the resident refrigerator in the unit pantry. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility Census: 9. Findings Included: a) Resident Refrigerator On [DATE] at 11:10 AM, a tour of the unit pantry was completed. The tour found the resident refrigerator containing multiple expired single-serve packets of condiments. The expiration dates found were [DATE] on the salad dressings and [DATE] for the tartar sauces. b) Facility Policy A review of the facility policy entitled Maintaining Kitchenettes dated ,d+[DATE] II D h. […]