Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Senior Care Center - St Marys during CMS and state inspections, most recent first.
Improper Food Storage, Labeling, and Thawing: Surveyors observed numerous expired and undated food items in the freezer, walk-in cooler, pantry, and spice storage, including meats, dairy, dry goods, and prepared items. Dietary staff confirmed there was no proper labeling and dating system for received, open, expiration, or use-by dates, and ground beef was being thawed submerged in water rather than in a sanitary manner consistent with policy.
Residents reported that a CNA used a loud, rude, and mean tone, refused requested care, and handled them roughly during ADL care. One resident said the CNA yelled at her and would not change her wet pants, another said the CNA yanked her gown, pulled her shoulder, and wiped her hard causing pain, and a third said the CNA pulled her leg hard and would not stop when told it hurt. Staff and police interviews also reflected concerns about the CNA’s conduct, including reports of rough and rushed care and failure to provide needed assistance.
A facility failed to consistently provide restorative nursing services after therapy for four residents with care plans and PT discharge recommendations for transfers, ambulation, and ROM. MDS records showed little or no restorative care during the look-back period, and residents reported receiving exercises only once or twice a week, or not at all, because the restorative CNA was often pulled to the floor due to staffing shortages. Staff interviews confirmed restorative care was not consistent and was provided only when the aide was available.
A resident with dementia and wandering behavior eloped from a room near an exit door after the door did not close properly, and staff did not know his whereabouts until family and police became involved. In a separate incident, another resident with mobility impairment fell in the shower when staff stepped away, the wheelchair was not locked, and the resident struck his head, later being diagnosed with a subarachnoid hemorrhage.
Insufficient nursing staffing led to delayed resident care, unanswered call lights, missed toileting and shower assistance, and reports of neglect and rough treatment. Residents and families described long waits for help, wet bedding and clothing, delayed catheter care, and staff not responding promptly, while staff confirmed the facility was short-staffed, sometimes with only two CNAs for the building and limited RN coverage. The staffing shortage also affected restorative services, and one resident eloped while the facility was unaware for several hours.
Hot water temperatures in bathroom sinks on B hall were found above the acceptable range in 13 of 38 resident rooms, with readings as high as 120.3 degrees F. A surveyor’s hand test showed the water was too hot to hold under for more than a few seconds, and the Maintenance Director stated the boiler serving B hall was set at 117 degrees F and he did not know why the sink water was hotter than the setting.
A resident with diagnoses including vascular dementia, AFib, HTN, and COPD had four pills left in a cup on the bedside table. The resident said an LPN had given the meds to take later and that she was allowed to self-administer daily, but the record had no completed self-administration assessment and no care plan focus for it. Staff later confirmed the meds were left in the room, identified them as gabapentin and sevelamer carbonate, and stated the resident was not capable of self-administering without supervision.
Improper Food Storage, Labeling, and Thawing
Penalty
Summary
The facility failed to ensure food was stored, prepared, and served in a sanitary manner in the kitchen. During a tour of the dietary department, surveyors observed multiple food items in the freezer, refrigerator/walk-in cooler, dry storage pantry, and spice rack that were expired, out of date, or missing required labels and dates such as received-by, open, expiration, or use-by dates. The facility’s policies required foods to be used before their expiration or use-by dates and required stock items to be dated with the delivery date, but staff were unable to provide the date items were delivered and confirmed that foods in the pantry were not properly labeled or dated. Surveyors found numerous examples of improper storage and dating, including frozen vegetables, breaded items, seasonings, cereal, beans, sauces, crackers, dairy items, meats, and other dry goods that had no labels, no dates, incomplete dates, or dates showing they were past use. Several items in the freezer and pantry were open and held closed with clips, rubber bands, or plastic wrap, while others were stored without any identifying information. In the walk-in cooler and surrounding storage areas, surveyors also observed items such as cottage cheese, shredded hash browns, hamburger buns, bologna, shredded cabbage, lettuce, cherry filling, and hard-cooked eggs that lacked proper labeling or dating, and one container of eggs had an unusual bad smell. Surveyors also observed meat thawing in a manner inconsistent with the facility policy. Two large rolls of ground beef were submerged in water in the two-compartment sink, and later the meat was still submerged in water in a large pan. A dietary cook stated the meat should be thawed under running water but did not know it should not be left submerged. The dietary staff and dietary manager confirmed the expired food items, the lack of a proper labeling and dating system, and the improper thawing of meat.
Residents Report Rough and Derogatory Care by CNA
Penalty
Summary
The facility failed to protect three residents from verbal and/or physical abuse by a CNA. The deficiency was identified through resident and staff interviews, record review, and review of the facility’s Abuse Prevention and Reporting policy. The policy defined abuse to include intentional or grossly negligent acts or omissions that cause injury, and defined verbal abuse as disparaging or derogatory oral, written, or gestured language toward residents or within their hearing distance. One resident with a history of CVA, Alzheimer’s disease, weakness, incontinence, and dependence for multiple ADLs reported that the CNA spoke to her in a mean manner, yelled at her, told her to get up and go by herself, and refused to change her wet pants when she needed help. The resident’s family confirmed that the CNA yelled at her and refused to provide care or help her to the bathroom. A staff member also confirmed that several residents had reported abuse by the CNA and that the CNA had been terminated in the prior weeks because of mistreatment, abuse, and neglect reported by residents. A second resident with hemiplegia and hemiparesis following CVA, dependence for toileting and personal care, and always incontinent of bowel and bladder stated that the CNA took off and snatched her gown, yanked it, pulled her left shoulder, and wiped her private area hard, causing pain. The resident said the CNA did not slow down or stop when told it hurt, and that she reported the incident to the night nurse. A third resident with Alzheimer’s disease, severe mobility impairment, incontinence, and a coccyx wound stated that the same CNA pulled her leg hard during care and would not stop when told it hurt. Another resident in the room confirmed the CNA did not empty the catheter drainage bag as requested and said the CNA was rough with the resident. Police were called to the facility, interviewed residents and staff, and documented concerns involving abuse, neglect, or exploitation by a staff member.
Inconsistent restorative nursing services after therapy
Penalty
Summary
The facility failed to consistently provide restorative nursing services after therapy ended for four residents who had restorative programs in their care plans and therapy discharge recommendations. The deficiency involved missed or inconsistent transfer assistance, ambulation or walking programs, and active or passive range of motion exercises for residents identified as needing ongoing restorative support to maintain function. R12 was admitted with chronic obstructive pulmonary disease, weakness, difficulty walking, muscle spasm of the calf, osteoporosis, and constipation, and had a BIMS score of 15. The care plan required training and skill practice in transfers and active range of motion for the bilateral upper and lower extremities six days per week, and PT discharge recommendations included a restorative range of motion program and restorative transfer program. However, the record contained no documentation of restorative nursing services for review, and the MDS showed restorative nursing services for transfer and active/passive range of motion on only one day during the seven-day look-back period. R13 was admitted with hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, along with muscle weakness, difficulty walking, hypothyroidism, and peripheral vascular disease, and had a BIMS score of 14. The care plan required walking and active range of motion to the bilateral lower extremities six days per week, and PT discharge recommendations included a restorative ambulation program and restorative range of motion program. The MDS showed no restorative nursing services during the seven-day look-back period, and the resident stated she received exercises only once a week or not at all, depending on whether the restorative CNA was working on the floor. R14 was admitted with dementia, hypothyroidism, type 2 diabetes mellitus, osteoarthritis, weakness, constipation, osteoporosis, and disorders of bone density and structure, and had a BIMS score of 12. The care plan required walking and active range of motion to the bilateral lower extremities six days per week, and PT discharge recommendations included a restorative ambulation program and restorative range of motion program. The MDS showed restorative nursing services for AROM and walking on only one day during the seven-day look-back period, and the resident stated the CNA did leg exercises only one to two times a week. R15 was admitted with a nondisplaced fracture of the second cervical vertebra and other complex medical conditions, had a BIMS score of 15, and the care plan required walking and active range of motion to the bilateral lower extremities six days per week. PT discharge recommendations included a restorative ambulation program and restorative range of motion program, but the MDS showed no restorative nursing services during the seven-day look-back period, and the resident stated no one was doing ROM, walking, transfer, or exercises with her. Staff interviews showed the restorative CNA was frequently pulled to work on the floor because of staffing shortages and did not provide restorative nursing on those days, with no restorative care on weekends. The DON and DHS staff acknowledged that the facility did not have a consistent restorative nursing program and that restorative exercises were done only occasionally or as much as possible when the restorative aide was not needed on the floor.
Failure to Supervise Residents During Elopement and Shower Care
Penalty
Summary
The facility failed to provide protective oversight and supervision to prevent elopement and ensure resident safety. The report states that one resident with dementia, severe cognitive impairment, and a documented wandering behavior was admitted with a Wander Guard order and a care plan identifying unsafe wandering. The resident was placed in a room at the end of Hall A next to a door that exited the facility, and the elopement risk assessment completed after the event scored the resident as high risk. The resident left the facility without signing out and was later found after walking to his previous residence, where he contacted family and was returned by police. The record and interviews show that the resident’s elopement occurred through the door at the end of A hall, which the Administrator later confirmed did not close properly. The facility incident report documented that the resident’s whereabouts were unknown after he left, and staff completed a resident count and checked doors after the event. Interviews with staff confirmed that the resident had exited the building and that other residents had also previously gone out through the front door and reached the parking lot. The Maintenance Director later stated that the door frame had several coats of paint and buildup that may have prevented the door from locking properly. The facility also failed to provide adequate supervision during a shower incident involving another resident who had a history of mobility impairment and required assistance. The resident was seated in a shower chair when staff turned away to provide privacy or attend to another stall, and the resident attempted to move to a wheelchair that was not locked. The wheelchair rolled, the resident slipped while wet, fell backward, and struck his head on the shower wall. The resident was sent to the hospital and was diagnosed with a subarachnoid hemorrhage. Interviews with the resident and staff confirmed that staff were present but not continuously close enough to prevent the fall.
Insufficient Nursing Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to provide enough nursing staff every day to meet residents’ needs and to have a licensed nurse in charge on each shift. Review of the facility policy stated staffing must meet the minimum hours required by law and be sufficient to meet each resident’s needs as identified in the plan of care. However, the facility assessment did not document the average daily census, the average hourly staffing needs for licensed nurses providing direct care, or the hours for nurse aides. The PBJ Staffing Data Report for FY Quarter 1 2026 showed excessively low weekend staffing, and the Administrator confirmed the PBJ data reflected low weekend staffing. Resident and family complaints repeatedly described delayed care and unanswered call lights. The grievance log included reports of delayed Foley catheter care, residents sitting in wet clothing and bedding for hours after calling for help, residents not being helped with toileting, CNAs ignoring requests, delayed bedtimes, missed showers, rough transfers, and staff being rude or neglectful. Resident Council minutes over several months also documented long response times, call lights not being answered, residents not receiving showers on schedule, residents being left alone in the shower, no one checking on residents at night, understaffing on weekends, and staff not assisting with getting residents up, changed, or put to bed. During the survey period, residents and staff described the facility as short-staffed, including reports of only two CNAs for the building at times and kitchen staff working 16-hour days. Interviews confirmed that the restorative aide was pulled to work as a floor CNA several days a week, limiting restorative services after therapy. On March 7, 2026, the staffing grid showed a 1.87 ppd staff-to-resident ratio, and that same day one resident eloped and was gone for several hours before the facility became aware. Staff also confirmed that on April 11, 2026, there were only two nurses and two CNAs in the facility, with one charge nurse performing both nursing and CNA duties because of the shortage.
Hot Water Temperatures Exceeded Safe Range in Resident Bathrooms
Penalty
Summary
The facility failed to ensure hot water temperatures were within the acceptable range of 110 degrees F or less in bathroom sinks for 13 of 38 resident rooms on B hall. During observations and temperature checks, surveyors found water temperatures of 112, 114, 115, 116, 118.0, 118.4, 119.3, 120.0, and 120.3 degrees F in adjoining bathrooms and a private bathroom on B hall. A surveyor’s initial hand test found the water so hot that her hand could not be held under it for more than a few seconds, and her hand remained bright pink for a long time afterward. During interview, the Maintenance Director stated the facility had four hot water heaters/boilers and that the boiler serving B hall was set at 117 degrees F. He said the setting had remained at that level since he started in October 2024, that he had not adjusted the thermostat, and that there were no issues with the heater/boiler. He also stated he did not know why the water temperature on B hall was higher than the boiler setting and did not know what temperature it should be set at. The facility policy reviewed defined an accident as an occurrence that interrupts or interferes with the orderly progress of a job or task and may include injury caused by defective equipment.
Unsecured Medications Left at Resident Bedside
Penalty
Summary
The facility failed to ensure that one sampled resident, R57, did not have unauthorized, unsecured medications at the bedside. R57 had diagnoses including vascular dementia, paroxysmal atrial fibrillation, hypertension, and chronic obstructive pulmonary disease, and the quarterly MDS showed a BIMS score of 15, indicating little to no cognitive impairment. The facility policy stated that self-administration of medications was permitted only when the licensed nurse and physician determined it was safe, and the physician wrote an order based on a self-administration observation. However, the resident record did not contain a completed assessment showing whether R57 was capable of self-administering medications, and the care plan had no focus area for self-administration. During observation, four pills were found in a medication cup on R57's bedside table, and the resident stated that a nurse had given her the pills to take later and that she had been authorized to self-administer medications daily. The September 2025 POF and MAR showed orders for gabapentin 100 mg three times daily and sevelamer carbonate 800 mg three times daily with meals. Later interviews with an LPN and the DHS confirmed the medications were left in the room and that R57 was not capable of self-administering medications without supervision. The DHS later identified the pills as gabapentin 100 mg and sevelamer carbonate 800 mg, matching the resident's ordered medications.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Saint Marys
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fernandina Beach Rehabilitation And Nursing Center | 8.3 mi | ★★★★★ | 10 | 0 |
| River City Nursing And Rehab Center | 17.4 mi | ★★★★★ | 2 | 0 |
| Lanier Rehabilitation Center | 18.4 mi | ★★★★★ | 0 | 0 |
| Aviata At Harts Harbor | 20.7 mi | ★★★★★ | 26 | 0 |
| Lakeside Center For Rehabilitation And Healing | 21.2 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.