Stella Maris, Inc.

In the surveyor’s words

From the most serious findings on record at Stella Maris, Inc., in the surveyor’s own words.

• Actual harm, isolatedF600Apr 9, 2025

  Based on review of a facility reported incident with documentation, medical record review, and staff interview, it was determined the facility failed to protect a vulnerable adult from physical abuse. Due to this deficient practice Resident #34 suffered physical harm. This was evident for 1 (#34) resident reviewed for 27 facility reported incidents reviewed during a complaint survey. The facility implemented effective and thorough corrective measures following this incident prior to the start of this survey. […]

• No harm, potential for more than minimal, patternF695Jul 28, 2026

  Based on observations, record review, and staff interviews, it was determined that the facility failed to: (1) ensure oxygen tubing and related oxygen delivery equipment were consistently dated and labeled in accordance with professional standards of practice; and (2) ensure a physician's order was available for oxygen administration for a resident receiving oxygen therapy. This deficient practice was evident for 5 (Residents #29, #87, #287, #3, and #6) of 5 residents reviewed for oxygen therapy during the facility's recertification survey. The findings include: Oxygen tubing is the flexible plastic line that safely delivers supplemental oxygen from a source like a portable tank, liquid oxygen system, or stationary concentrator directly to the user. […]

• No harm, potential for more than minimal, patternF609Apr 9, 2025

  Based on reviews of facility reported incidents, complaint, record review, and interview, it was determined the facility failed to report allegations of abuse to the regulatory agency, the Office of Health Care Quality (OHCQ) within 2 hours of the allegation and failed to report bruises of unknown origin to OHCQ. This was evident for 12 (#22, #24, #47, #4, #56, #34, #42, #7, #21, #25, #19, #36 ) of 71 residents reviewed during a complaint survey. The findings include: 1) On 3/26/25 at 11:47 AM a review of facility reported incident MD00195422 was conducted. […]

• No harm, potential for more than minimal, patternF610Apr 9, 2025

  Based on review of facility administrative records, facility investigations, complaint, medical record review, and staff interview, it was determined the facility failed to thoroughly investigate incidents of alleged abuse, neglect, and bruises of unknown origin. This was evident for 10 (#22, #65, #47, #4, #56, #42, #7, #26, #19, #36) of 71 residents reviewed during a complaint survey. The findings include: 1) On 3/26/25 at 11:47 AM a review of facility reported incident MD00195422 was conducted. […]

• No harm, potential for more than minimal, patternF812Apr 9, 2025

  Based on observations, interviews with staff, and review of complaint, it was determined that the facility failed to store food and monitor temperatures in a manner that maintains professional standards of food service safety. This practice had the potential to affect all residents eating food prepared in the facility's kitchen. The findings include: 1. The facility staff failed to ensure food is served to residents at temperatures to ensure food safety. On [DATE] at 12:29 PM the Surveyor observed lunch meal service to the Residents on the 1 [NAME] nursing unit. At that time the facility staff were setting up meal service and residents were seated in the dining room. […]