Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St. Mary's Nursing Center Inc during CMS and state inspections, most recent first.
Failure to Timely Report Alleged Abuse: A resident was found with bruising of unknown origin and stated that an aide had been rough during care. A GNA reported the bruise to an RN while the resident complained of shoulder pain, but the RN did not promptly notify the nursing supervisor and waited until the next morning to inform the DON.
An LPN administered multiple medications to two residents outside the scheduled eMAR times, including Senna-S, Bupropion ER, and Eliquis, despite physician orders for specific dosing schedules. Survey review also found repeated late administrations for another resident involving Eliquis, Gabapentin, and Lantus, and the DON acknowledged that late medications should prompt physician notification.
Unsafe medication administration and lack of self-administration assessment were identified for a resident. During a medication pass, an LPN saw the resident holding Saline Mist Nasal Spray and later learned the resident had already taken it, but did not know how much was used. The LPN acknowledged the resident did not have a physician order or assessment allowing self-administration, and the DON confirmed the nurse should have administered the medication.
A resident continued receiving daily Enoxaparin for DVT prophylaxis even though the resident had become ambulatory and the record lacked documentation supporting the ongoing need for the medication. The resident said the injection was not used at home and was unsure why it was being given, while the DON was unaware of the reason for continuation and the PA-C stated she did not know the resident was ambulatory when she evaluated the resident.
The facility was found deficient in maintaining a safe and homelike environment due to abraded wall markings behind bed headboards in five resident rooms on the 4th floor. The Facilities Director was unaware of these issues, despite a system for reporting maintenance concerns. Previous attempts to address the problem were unsuccessful.
A facility failed to transcribe a physician's order for a wound care consult for a resident with moisture-associated skin damage. The physician had ordered the resident to be turned every two hours and to obtain a wound care consult, but the consultation was not conducted. The DON confirmed that the nurse did not carry over the order, leading to the oversight.
Two residents experienced a lack of respect and privacy in a facility. One resident's call for assistance was ignored, leading to a delay in receiving help with a bedpan. Another resident's Foley drainage bag was left uncovered and visible from the hallway, compromising their privacy. These incidents highlight deficiencies in maintaining resident dignity and privacy.
The facility failed to invite two residents to participate in their care planning meetings, as revealed during a survey. One resident had not been invited since July 2023, and another was unaware of any meetings despite a recent MDS assessment. The social worker admitted to not documenting invitations, leading to a deficiency in resident involvement in care planning.
A facility failed to ensure resident safety during a transfer, resulting in a fall and hospitalization, and did not maintain proper seizure precautions for a resident with epilepsy. The resident fell when a GNA moved a wheelchair backward during a transfer, and another resident's bedrails were only partially padded despite an order for full padding as a seizure precaution.
The facility staff failed to accurately document the walk-in refrigerator temperatures, relying on an inaccurate outside thermometer instead of the correct inside thermometer. This led to consistent documentation of temperatures above the required 40 degrees, despite staff awareness of the correct temperature standards.
A resident was transferred to a hospital for emergency treatment and later denied readmission to the facility without prior notice to the resident or their representative. The facility's Administrator and DON cited unrealistic care expectations from the family as the reason for the decision, which was made after a care conference with the resident's POA.
A resident was not prepared for discharge from a facility, as the facility failed to provide notice to the resident or their representative. After being transferred for emergency treatment and admitted to a hospital for sepsis, the facility decided not to allow the resident's return, citing unrealistic care expectations from the family. The decision was confirmed by the Administrator and DON, despite a care conference where additional care interventions were requested.
A facility failed to allow a resident to return after hospitalization, citing unrealistic care expectations from the family. The resident was initially transferred for emergency treatment due to a suspected infection. Despite a care conference where the family requested changes to the care plan, the facility later refused readmission, stating they could not meet the family's expectations. The Administrator confirmed the decision, acknowledging the facility's capability to provide care but unwillingness to comply with the family's demands.
A resident was involuntarily discharged from a facility without prior notice, violating CMS regulations. The resident was transferred to a hospital for emergency treatment, and upon the family's request for a care conference, the facility initially agreed to consider changes to the care plan. However, the facility later refused to readmit the resident, citing unrealistic care expectations from the family, causing psychosocial harm to the resident.
A facility failed to document the discharge of a resident transferred for emergency treatment and later admitted to a hospital for sepsis. The resident's POA requested a care conference to discuss post-hospital care, but the facility later refused the resident's return, citing unrealistic care expectations. The facility did not document the discharge or provide notice, which was confirmed by the administration.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to ensure staff reported an allegation of abuse in a timely manner after bruising of unknown origin was discovered on Resident #74. During the investigation, a GNA stated that while getting the resident changed and ready for bed, the resident complained of right shoulder pain and the GNA saw the resident’s arm and reported it to the nurse. Another statement from the RN indicated she was made aware of the resident’s right arm bruising by the GNA while providing care, and the resident complained of pain to the right shoulder, which was treated with routine Tylenol and was effective. The DON confirmed during interview that the nurse failed to report the resident’s allegation timely and that disciplinary action had been taken for failure to report. The disciplinary record showed that after the bruise was discovered and the resident stated the bruise was caused by the GNA being rough, the nurse reported to the on-call provider but did not report the allegation to the nursing supervisor that night, waiting until the following morning to notify the DON.
Medication Administration Not Given at Ordered Times
Penalty
Summary
The facility failed to ensure medications were administered as ordered by the physician and according to accepted standards of nursing practice, including giving medications at the correct time. During a medication administration observation, an LPN prepared and administered Senna-S to Resident #127 at approximately 10:00 AM even though the eMAR showed a scheduled time of 8:00 AM and the physician order directed two tablets by mouth twice daily for constipation. In a separate observation, the same LPN administered Bupropion ER 150 mg and Eliquis 5 mg to Resident #58 at approximately 10:25 AM, although the eMAR listed both medications for a 9:00 AM administration time and the physician orders directed each medication twice daily for depression and atrial fibrillation, respectively. The surveyor also reviewed Complaint #364453 regarding Resident #128 and found multiple examples of medications being given outside the scheduled times in 2024 and 2025. Documentation reviewed showed late administrations of Eliquis 5 mg, Gabapentin 100 mg, and Lantus insulin 14 units, including doses scheduled for 0800 that were given at 09:46 AM, 09:15 AM, 09:55 AM, and 09:48 AM, and doses scheduled for 2000 that were given at 21:40, 22:04, 21:26, 21:13, and 21:20. The DON stated that licensed staff had been administering medications on two different floors since 2024 and that the process had been working well, and later acknowledged that when medications appear late on the eMAR, the nurse should notify the physician for direction regarding administration.
Unsafe Medication Self-Administration
Penalty
Summary
The facility failed to ensure safe medication administration and proper assessment for self-administration for one resident. During a medication pass observation, an LPN was observed administering medications when the resident entered the room in a wheelchair holding a medication in hand. The resident stated the medication, identified as Saline Mist Nasal Spray, had already been taken, and the LPN retrieved it and returned to the medication cart. When questioned, the LPN stated she did not know how much medication the resident had administered and acknowledged she should have observed the resident. The LPN also confirmed that the resident did not have a physician order or assessment authorizing self-administration of medications. The DON later acknowledged that although the resident was alert and oriented, the resident needed to be assessed and have a physician order to self-administer medications, and confirmed the nurse should have administered the medication.
Unnecessary anticoagulant continued after resident became ambulatory
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs when Resident #32 continued to receive Enoxaparin Sodium 40 mg subcutaneously once daily for DVT prophylaxis after the resident was no longer immobile. The medical record showed the resident was admitted in February 2026 with documentation indicating immobility, but the record lacked documentation showing the clinical rationale for continuing Enoxaparin after that condition had changed. During the survey, the resident stated not knowing why the daily injection was being given and reported not taking the medication at home, explaining that the admission was for rehabilitation and the plan was to return home. The DON stated she was unaware of the reason the medication was still being given, and the Speech Therapist/Rehabilitation Director verified the resident had been ambulatory since admission. The PA-C who evaluated the resident stated she was not aware the resident was ambulatory at the time of her visit and said she would have discontinued the medication if she had known.
Facility Fails to Maintain Good Repair in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by the presence of abraded wall markings in five resident rooms on the 4th floor nursing unit. These observations were made on November 20, 2024, at various times throughout the day. The markings, which resembled scratch-like marks, were found behind the headboards of the beds in these rooms. The issue was consistent across multiple rooms, indicating a broader problem with the facility's maintenance practices. During an interview with the Facilities Director, it was revealed that staff members are expected to fill out maintenance slips for any concerns, which are checked hourly by maintenance staff. However, the Facilities Director was unaware of any maintenance issues on the 4th floor. He acknowledged that the facility has had ongoing issues with wall damage behind bed headboards due to staff pushing beds against the walls and adjusting bed heights, which causes scratches. Despite previous attempts to address this issue, the problem persisted, leading to the deficiency noted by the surveyor.
Failure to Transcribe Physician's Order for Wound Care Consult
Penalty
Summary
The facility failed to transcribe a physician's order for a wound care consult for a resident, leading to a deficiency. The resident had a documented change in skin condition, specifically moisture-associated skin damage between the buttocks, noted on 10/5/24. The physician ordered that the resident be turned every two hours and a wound care consult be obtained. However, upon review of the medical record on 11/20/24, it was found that the wound consultation had not been conducted. An interview with the Director of Nursing revealed that the nurse did not carry over the order for the wound consultation, resulting in the oversight.
Failure to Respect Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by two specific incidents involving residents. In the first incident, a resident's call light was activated, indicating a need for assistance. Environmental Services Staff entered the room but did not provide the necessary help, as the resident urgently needed a bedpan. The resident's call light was activated again, and despite the presence of a GNA in the hallway, the resident's request was dismissed as a control issue. Eventually, the Unit Manager intervened to assist the resident, but the delay in response highlighted a lack of respect for the resident's needs. In the second incident, a resident with a Foley drainage bag attached to their bed was observed with the bag uncovered and visible from the hallway. This lack of privacy was noted on two separate occasions, and the LPN acknowledged that the bag should have been covered. The visibility of the drainage bag from the hallway without a privacy cover demonstrated a failure to maintain the resident's dignity and privacy.
Failure to Invite Residents to Care Plan Meetings
Penalty
Summary
The facility failed to ensure that residents were offered the opportunity to participate in their care planning process by being invited to their care plan meetings. This deficiency was identified for two residents during the survey. Resident #31 was unaware of care plan meetings and expressed a desire to participate. A review of the resident's medical records revealed that they had not been invited to any care plan meetings since July 2023. The social worker acknowledged that the resident had not been invited and admitted that improvements could be made in inviting residents to these meetings. Similarly, Resident #12 was also unaware of any care plan meetings. A review of their medical records showed that the last documented care plan meeting was in March 2024, despite a recent MDS assessment in October 2024. The social worker confirmed that there was no documentation of Resident #12 being invited to care plan meetings and admitted to not documenting when residents are invited. The surveyor noted this concern at the time of exit, highlighting the facility's failure to ensure resident participation in care planning.
Deficiencies in Resident Safety and Seizure Precautions
Penalty
Summary
The facility failed to ensure the safety of a resident during a transfer, which resulted in a fall and subsequent hospitalization. The resident, who was cognitively intact and dependent on staff for mobility transfers, reported that a Geriatric Nursing Assistant (GNA) spun them too fast during a transfer from the toilet, leading to the fall. The investigation revealed that the GNA unlocked the wheelchair wheels and moved it backward, causing the resident to lean forward and fall, despite the GNA's attempt to grab the resident by the gait belt. Additionally, the facility did not maintain proper seizure precautions for another resident with epilepsy. The resident's medical record indicated an active order for padded side rails as a seizure precaution, but observations showed that the bedrails were only partially covered with cushions, leaving a portion near the head of the bed exposed. Interviews with staff confirmed that the bedrails should have been fully padded, but they were not. These deficiencies highlight the facility's failure to maintain adequate safety measures during resident transfers and to ensure proper seizure precautions, as evidenced by the observations and staff interviews conducted by the surveyors.
Inaccurate Temperature Documentation in Walk-In Refrigerator
Penalty
Summary
The facility staff failed to ensure accurate documentation of the walk-in refrigerator temperatures, as observed during an environmental kitchen food services inspection. On the initial inspection, the temperature logs were not found near the refrigerator but were instead kept in a book near the dietician's office. The thermometer inside the refrigerator showed a temperature of 38 degrees, while the logs documented a temperature of 42 degrees for the same morning. The dietician acknowledged that the thermometer inside the refrigerator was accurate, whereas the one outside was sometimes inaccurate. Further inspection revealed that the outside thermometer was malfunctioning, as it was blinking and not registering a temperature, while the inside thermometer read 39 degrees. The temperature logs showed consistent documentation of temperatures above the required 40 degrees, with several entries at 45 degrees. The cook staff confirmed that she documented the temperature from the outside thermometer, despite knowing the correct temperature should be 40 degrees or less. The dietician admitted that the dietary staff were documenting incorrect temperatures from the outside thermometer instead of the accurate readings from the inside thermometer.
Failure to Provide Adequate Discharge Notice
Penalty
Summary
The facility failed to provide adequate notice to a resident and their representative prior to discharge. The incident involved a resident who was transferred from the facility for emergency treatment due to symptoms of a urinary tract infection leading to sepsis. The resident was admitted to a local hospital for observation. Despite a care conference held with the resident's power of attorney (POA), the facility later informed the POA that the resident would not be allowed to return after hospital discharge, citing the family's unrealistic care expectations. This decision was made without prior notice to the resident or their representative, as required. Interviews with the facility's Administrator and Director of Nursing (DON) confirmed the refusal to readmit the resident, attributing the decision to the family's changing and immediate care expectations. The Administrator expressed a willingness to accept regulatory penalties rather than accommodate the family's demands. The surveyor noted the facility's failure to provide the required notice, which was acknowledged by the Administrator and DON.
Failure to Prepare Resident for Discharge
Penalty
Summary
The facility failed to prepare a resident for discharge, as evidenced by the lack of notice provided to the resident or their representative prior to discharge. The resident was initially transferred from the facility for emergency treatment after being observed moving slower than usual, and was subsequently admitted to a local hospital for observation due to sepsis caused by a urinary tract infection. Despite a care conference being held with the resident's power of attorney (POA), the Administrator, Director of Nursing (DON), and a Social Worker, where additional interventions to the resident's care plan were requested, the facility later informed the POA that the resident would not be allowed to return after hospital discharge. The Administrator and DON confirmed the decision to refuse the resident's return, citing unrealistic care expectations from the family. The Administrator expressed a willingness to accept regulatory penalties rather than readmit the resident under the family's expectations. The DON noted a history of frequent visits and criticisms from the POA regarding the care provided. The surveyor highlighted the facility's failure to adequately prepare the resident or their representative for discharge, which the Administrator and DON acknowledged.
Facility Refusal to Readmit Resident Post-Hospitalization
Penalty
Summary
The facility failed to allow a resident to return after being transferred for emergency treatment, which was identified during a complaint survey. The resident was initially transferred to a hospital for observation due to a suspected systemic infection caused by a urinary tract infection. The facility did not provide the resident or their representative with notice prior to the discharge decision. The resident's power of attorney (POA) requested a care conference to discuss the resident's care post-hospitalization, which was attended by the facility's Administrator, Director of Nursing (DON), and a social worker. During this meeting, the POA requested additional interventions to the resident's care plan, which the Administrator said would be considered. Later, the facility informed the POA that they would not allow the resident to return, citing the family's unrealistic care expectations. The Administrator confirmed the refusal to readmit the resident, despite acknowledging that the facility could provide the necessary care. The DON provided context on the history of interactions with the POA, noting frequent visits and criticisms of the care provided. The Administrator expressed a willingness to accept regulatory penalties rather than readmit the resident under the family's expectations.
Failure to Provide Notice for Involuntary Discharge
Penalty
Summary
The facility's administration failed to provide leadership to ensure compliance with CMS regulations regarding the involuntary discharge of a resident. This deficiency was identified during a complaint survey involving a resident who was transferred to a hospital for emergency treatment due to a suspected systemic infection. Upon review, it was found that the facility did not provide the required notice to the resident or their representative prior to the discharge, which is a violation of the regulations. The situation escalated when the resident's power of attorney (POA) requested a care conference to discuss the resident's care plan after hospital discharge. During the conference, the POA requested additional interventions, which the facility initially agreed to consider. However, later that day, the facility informed the POA that they would not allow the resident to return, citing unrealistic care expectations from the family. The facility's decision not to readmit the resident without prior notice caused psychosocial harm to the resident, as the facility was deemed to have the appropriate staff and environment to meet the resident's needs. Interviews with the Administrator and DON confirmed the refusal to readmit the resident and acknowledged the lack of leadership in handling the situation appropriately.
Failure to Document Resident Discharge and Provide Notice
Penalty
Summary
The facility failed to document the discharge of a resident who was transferred for emergency treatment and subsequently admitted to a local hospital for observation due to sepsis caused by a urinary tract infection. Upon review of the resident's medical records, there was no documentation indicating that the facility discharged the resident or provided notice to the resident or their representative prior to discharge. This deficiency was identified during a complaint survey involving five residents. An interview with the resident's power of attorney (POA) revealed that a care conference was requested to discuss the resident's care post-hospital discharge. During the conference, the POA requested additional interventions to the care plan, which the facility agreed to consider. However, later that day, the facility informed the POA that they would not allow the resident to return, citing unrealistic care expectations. The facility's administrator confirmed the decision, stating they could provide care but not at the level expected by the POA. The surveyor noted the lack of discharge documentation, and the facility's administration acknowledged the oversight.
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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 Leonardtown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Chesapeake Shores Nursing Center | 9.1 mi | ★★★★★ | 13 | 0 |
| Asbury Solomons | 9.7 mi | ★★★★★ | 0 | 0 |
| Solomons Nursing And Rehab Center | 10.4 mi | ★★★★★ | 31 | 0 |
| Charlotte Hall Veterans Home | 14.5 mi | ★★★★★ | 0 | 0 |
| Calvert County Nursing Ctr. | 18.2 mi | ★★★★★ | 29 | 0 |
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