Cycle 1
Health 2024-11-22 · Fire 2024-11-22
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Leonardtown, MD
St. Mary's Nursing Center Inc
5-star overall rating with 5-star inspections with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
21585 Peabody Street, Leonardtown, MD
(301) 475-8000
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
160
Certified beds
Average residents
116
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.57
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.91
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.22
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.70
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.48
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.19
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.59
CMS adjusted RN staffing hours
Adjusted total hours
3.81
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
985
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.36
Composite VBP score used to determine payment impact.
Payment multiplier
1.0164
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 19.14% · Performance 16.77% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
10
Baseline 7.39% · Performance 4.46% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
3.13
Baseline 40.96% · Performance 50.89% · Measure score 3.13 · Achievement 3.13 · Improvement 0
Adjusted total nurse staffing
1.42
Baseline 2.95 hours · Performance 3.48 hours · Measure score 1.42 · Achievement 1.42 · Improvement 1.36
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.23% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 297 · Observed rate 8.08% · Lower 95% interval 8.36% |
| Discharge to community | 68.09% |
50.57%
17.5 pts better
|
Better than the National Rate · Eligible stays 266 · Observed rate 68.05% · Lower 95% interval 62.68% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 88.05% |
95.27%
7.2 pts worse
|
Numerator 140 · Denominator 159 |
| Falls with major injury | 0.63% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 159 |
| Discharge self-care score | 66.91% |
53.69%
13.2 pts better
|
Numerator 91 · Denominator 136 |
| Discharge mobility score | 80.88% |
50.94%
29.9 pts better
|
Numerator 110 · Denominator 136 |
| Pressure ulcers or injuries, new or worsened | 2.52% |
2.29%
0.2 pts worse
|
Numerator 4 · Denominator 159 · Adjusted rate 2.99% |
| Healthcare-associated infections requiring hospitalization | 4.46% |
7.12%
2.7 pts better
|
Better than the National Rate · Eligible stays 166 · Observed rate 0.6% · Lower 95% interval 2.74% |
| Staff COVID-19 vaccination coverage | 1.3% |
8.2%
6.9 pts worse
|
Numerator 2 · Denominator 154 |
| Staff flu vaccination coverage | 93.4% |
42%
51.4 pts better
|
Numerator 198 · Denominator 212 |
| Discharge function score | 72.79% |
56.45%
16.3 pts better
|
Numerator 99 · Denominator 136 |
| Transfer of health information to provider | 95.33% |
95.95%
0.6 pts worse
|
Numerator 102 · Denominator 107 |
| Transfer of health information to patient | 96.97% |
96.28%
0.7 pts better
|
Numerator 32 · Denominator 33 |
| Resident COVID-19 vaccinations up to date | 37.23% |
25.2%
12 pts better
|
Numerator 35 · Denominator 94 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.3
0.3 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.2
0.3 pts worse
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.3 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 82.9% |
91.9%
9 pts worse
|
93.4%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 51.6% · Q2 89.0% · Q3 93.7% · Q4 97.0% · 4Q avg 82.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.6%
3.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.9% |
2.3%
1.6 pts worse
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 4.4% · Q3 1.1% · Q4 5.1% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 17.2% |
21.4%
4.2 pts better
|
11.4%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 18.2% · Q3 18.5% · Q4 10.8% · 4Q avg 17.2% |
| Percentage of long-stay residents who lose too much weight | 1.7% |
5.7%
4 pts better
|
5.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.3% · Q3 2.2% · Q4 0.0% · 4Q avg 1.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.3% |
16.1%
6.8 pts better
|
19.6%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 6.7% · Q3 12.0% · Q4 12.2% · 4Q avg 9.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.4% |
15.3%
11.9 pts better
|
16.7%
13.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 2.9% · Q3 1.3% · Q4 5.3% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 1.1% |
0.0%
1.1 pts worse
|
0.1%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.1% · Q3 1.1% · Q4 1.0% · 4Q avg 1.1% |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.8% |
26.6%
11.8 pts better
|
16.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 12.3% · Q3 13.7% · Q4 18.3% · 4Q avg 14.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.1% |
22.9%
6.8 pts better
|
14.9%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 12.3% · Q3 16.5% · Q4 22.1% · 4Q avg 16.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.5%
0.7 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 2.2% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.7% |
25.4%
0.7 pts better
|
19.8%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 30.2% · Q3 24.8% · Q4 28.3% · 4Q avg 24.7% |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
6.3%
4 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 4.1% · Q3 0.0% · Q4 1.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.6% |
78.4%
12.2 pts better
|
81.7%
8.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.0% · Q2 89.1% · Q3 91.4% · Q4 89.3% · 4Q avg 90.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.1% |
9.9%
3.2 pts worse
|
12.0%
1.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.1% · Observed 12.6% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.3%
0.7 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.0% |
80.6%
14.4 pts better
|
79.7%
15.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.4% |
21.2%
5.8 pts better
|
23.9%
8.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.4% · Observed 13.7% · Expected 21.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-08-27 · Fire 2019-08-27
10 health deficiencies
Top issue: Resident Rights (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2018-06-06 · Fire 2018-06-06
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-28
F · Potential for more than minimal harm
2024-11-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-01-28
E · Potential for more than minimal harm
2024-11-22
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-01-28
E · Potential for more than minimal harm
2024-11-22
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-01-28
D · Potential for more than minimal harm
2024-11-22
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-01-28
D · Potential for more than minimal harm
2024-11-22
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-01-28
D · Potential for more than minimal harm
2024-11-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-28
D · Potential for more than minimal harm
2019-08-27
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2019-10-01
D · Potential for more than minimal harm
2019-08-27
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2019-10-01
D · Potential for more than minimal harm
2019-08-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-10-01
D · Potential for more than minimal harm
2019-08-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-10-01
E · Potential for more than minimal harm
2018-06-06
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2018-07-28
D · Potential for more than minimal harm
2018-06-06
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2018-09-13
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-11-22
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-11-22
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-11-22
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-11-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-11-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-11-22
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-07-26
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-26
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-26
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-26
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-26
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-08-09
E · Potential for more than minimal harm
2019-08-27
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-10-10
E · Potential for more than minimal harm
2019-08-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-10-10
D · Potential for more than minimal harm
2019-08-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-10-10
D · Potential for more than minimal harm
2019-08-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-10-10
C · Minimal harm
2019-08-27
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2019-10-10
E · Potential for more than minimal harm
2018-06-06
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2018-07-21
D · Potential for more than minimal harm
2018-06-06
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2018-07-21
Penalties and ownership
What sits behind the stars
Ownership
Burton, Charles
Corporate Director · Individual
Densford, Joseph
Corporate Director · Individual
Densford, Joseph
Corporate Officer · Individual
Farrell, James
Corporate Director · Individual
Hall, Trace
W-2 Managing Employee · Individual
Hodges, Lois
W-2 Managing Employee · Individual
Kaur, Kirandeep
Contracted Managing Employee · Individual
Kubinec, Tracy
Corporate Director · Individual
Kubinec, Tracy
Corporate Officer · Individual
Lancaster, Harry
Corporate Director · Individual
Morgan, Christine
Corporate Director · Individual
Mortensen, Denise
Corporate Director · Individual
Prochnow, Terry
Corporate Director · Individual
Sterling, Judith
Corporate Officer · Individual
Viar, Willard
Corporate Director · Individual
Viar, Willard
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Chesapeake Shores Nursing Center
Lexington Park, MD
3-star overall rating with 3-star inspections with $47,254 in total fines with 25 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Asbury Solomons
Solomons, MD
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#3
Solomons Nursing And Rehab Center
Solomons, MD
1-star overall rating with 1-star inspections with abuse icon flag with $225,946 in total fines with 19 recent health deficiencies with 20 fire-safety deficiencies in the latest cycle
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