St. Mary's Nursing Center Inc

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF584Nov 22, 2024

  Based on observation and interview, it was determined that the facility failed to ensure the facility was in good repair. This was evident for 5 resident rooms observed on the 4th floor nursing unit during the survey. The findings include: On 11/20/24 at 08:31 AM, an observation of room [ROOM NUMBER] revealed that the A bed (the bed closest to the entry door) had several vertical, abraded wall markings. These markings varied in length and width which resembled scratch-like marks behind the headboard of the bed. On 11/20/24 at 01:51 PM, an observation of room [ROOM NUMBER] revealed that the A bed (the bed closest to the entry door) had several vertical, abraded wall markings. […]

• No harm, potential for more than minimal, isolatedF609Mar 12, 2026

  Based on administrative review and interviews with facility staff it was determined the facility failed to ensure staff reported allegations of abuse timely after bruising of unknown origin on a resident was discovered This was found to be evident in 1(#74) of 6 residents' facility reported incidents reviewed during the annual Medicare/Medicaid survey. The findings include:Intake # 2657368 was reviewed on 3/11/26 at 11:00AM for resident # 74 for an injury of unknown origin. Intake details indicate that the resident was noted with bruising to the right arm and reported that an aide was rough with him/her. […]

• No harm, potential for more than minimal, isolatedF658Mar 12, 2026

  Based on observation, record review, and interview, the facility failed to ensure medications were administered as ordered by the physician and according to accepted standards of nursing practice, including administering medications at the correct time. This was evident for 3 (#127, #58, #128) of 4 residents observed and reviewed for medication administration. According to accepted standards of nursing practice, including the patient medication rights outlined in the Maryland Nurse Practice Act, medications must be administered according to the right time, meaning medications should be administered at the time intended by the prescriber to maintain therapeutic effectiveness. The Findings Include: 1. […]

• No harm, potential for more than minimal, isolatedF684Mar 12, 2026

  Based on observation and staff interview it was determined the facility failed to ensure safe medication administration and proper assessment for self-administration. This was evident for 1 (#110) of 4 residents reviewed for medication administration.The findings include:Medication pass observation was conducted on 3/9/26 at approximately 11:14 AM. Licensed Practical Nurse (LPN), Staff #22, was observed administering medications to residents. At that time, Resident #110 was observed entering his/her room via wheelchair holding medication in hand.Staff #22, accompanied by the surveyor, entered the resident's room and asked if the medication had been taken. Resident #110 responded, yes. […]

• No harm, potential for more than minimal, isolatedF757Mar 12, 2026

  Based on medical record review, observation, and staff interview, the facility failed to ensure a medication was clinically indicated and evaluated for continued need. This occurred for 1 (#32) of 5 residents reviewed for unnecessary medications during the annual survey.The findings include:Review of the medical record for Resident #32 on 3/10/2026 revealed the resident was receiving Enoxaparin Sodium Solution 40 mg/0.4 mL, administered 40 mg subcutaneously once daily for deep vein thrombosis (DVT) prophylaxis.Further review of the medical record revealed the resident was admitted to the facility in February of 2026 with documentation indicating immobility. The clinical record revealed the resident was evaluated by Physician Assistant-Certified (PA-C) staff # 28 on 3/5/2026. […]