Mary Anna Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to implement a person-centered care plan for each resident to maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (#1) of 18 sampled residents. The facility failed to ensure care-planned interventions for falls were implemented. Findings:Resident # 1 Review of the record for Resident #1 revealed an admission date of 08/08/2024 with diagnoses that included type 2 diabetes mellitus with diabetic neuropathy, gastroesophageal reflux disease, vitamin D deficiency, osteoarthritis, dementia, hypertension, hyperlipidemia, and history of falling. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 7 which indicated Resident #1 had severe cognitive impairment with daily decision making. Further review revealed Resident #1 required supervision/touch assist with chair to chair and bed to chair transfers. Review of the quarterly fall risk assessment dated [DATE] revealed a score of 18 which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure a resident maintained acceptable parameters of nutritional status by failing to follow their policy and procedure when a significant weight loss was identified for 1 (#2) of 3 residents reviewed for nutrition. Findings:Review of the facility undated Policy and Procedure: Weight Loss Management revealed the following, in part:III. Definitions:Significant Weight Loss: 1 month: >5% loss of body weightIV. ProcedureC. Identification of Weight Loss:1. If a significant weight loss is identified, nursing staff must notify the dietitian, attending physician, and the responsible party within 24 hours.2. Place the resident on the facility's High Risk /Weight Management List for closer monitoring.D. Evaluation and Intervention:2. IDT Meeting: Within 72 hours of identifying significant weight loss, the IDT (Dietician, Nurse, Physician, and Activity Director) will meet to review the plan of care.3. Interventions: Implement appropriate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that nurses have specific competencies and skill sets necessary to care for residents' needs by not: 1) clarifying the correct dosage of a medication for 2 (#1, #16) of 5 residents observed for medication administration and 2) notifying the physician with changes in condition for 1 (#37) of 2 residents reviewed for hospitalization. Findings:Resident #1Review of the record for Resident #1 revealed an admission date of 08/08/2024 with diagnoses that included type 2 diabetes mellitus with diabetic neuropathy, gastroesophageal reflux disease, vitamin D deficiency, osteoarthritis, dementia, hypertension, hyperlipidemia, and history of falling. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 7 which indicated Resident #1 had severe cognitive impairment with daily decision makingReview of the record for Resident #1 revealed a physician's order dated 12/11/2025 for Voltaren 1% external gel topical apply to bilateral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews the facility failed to ensure residents received mail on Saturdays. This deficient practice had the potential to affect 35 residents residing in the facility. Findings,During a resident council interview on 03/16/2026 at 12:45 p.m., Resident #19 reported they receive mail Monday through Friday. Resident #19 reported they do not receive mail on Saturdays. On 03/16/2026 at 1:10 p.m. an interview with S14Office Manager revealed she goes to the post office Monday through Friday and picks up all of the facility's mail and the residents' mail from the post office box. S14Office Manager reported she passes out the residents' mail to them Monday through Friday after she returns from the post office. S14Office Manager reported she does not go to the post office to pick up mail on Saturdays. On 03/16/2026 at 1:15 p.m. an interview with S1Administrator reported the facility's mail and the residents' mail are both delivered to the provider's post office box at the post office. S1Administrator reported S14Office Manager has the key to the post office box and goes to the post…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews and observations, the facility failed to provide the care and services that is in accordance with professional standards of practice for 1 (#5) of 1 resident reviewed for respiratory care. The facility failed to date nebulizer tubing and properly store nebulizer tubing and face mask in a plastic bag when not in use. Findings:Review of the provider's nursing procedure for compliance with changing oxygen/nebulizer tubing/humidifier policy, undated policy, revealed in part: Policy: to aid in the prevention of the spread of infection and the buildup of bacteria on the tubing over time. Oxygen and nebulizer tubing will be changed two times per month on the 1st and 15th. Tubing will be dated at this time. LPN will check upon each shift that tubing is still in designated bag and labeled properly and document it on EMAR for that shift. If tubing is not properly stored it should be replaced and dated at this time.Record review revealed Resident #5 was admitted to the facility on [DATE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. The facility failed to implement the EBP policy for 2 (#14, #5) of 2 residents reviewed for EBP. Findings: Resident #5 Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus without complications, pain in right hip, aftercare following joint hip replacement surgery, presence of right artificial hip joint, fracture of the neck of right femur sequela, and chronic venous hypertension (idiopathic) with ulcer and inflammation of unspecified lower extremity. Review of current March 2026 Physician Orders included the following: 1) 02/11/2026: Cleanse incision to right hip daily with hydrogen peroxide, apply thin layer of bactroban, cover with 4x4 and tape daily and as need for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to ensure residents were free from physical restraints imposed for the purpose of discipline or convenience for 4 (#11, #20, #24, and #29) of 5 (#11, #15, #20, #24 and #29) residents reviewed for restraints. The facility failed to 1) obtain a consent, 2) have a physician's order and 3) failed to appropriately assess residents prior to placing the bolsters on the bed. Findings: Review of the facility's Respect and Dignity Policies and Procedures dated 03/02/2023 revealed ____ ____ Nursing Home will ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Should ____ ____ staff decide to use a restraint, it must be the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. It is our intent at ____ ____ for each resident to attain and maintain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident was free of accident hazards as is possible by failing to ensure appropriate interventions were attempted after each fall for 1 (#11) of 1 residents sampled for falls. Findings: Review of resident #11's medical record revealed an admission date of 08/15/2022 with diagnoses including Alzheimer's disease, wedge compression fracture of Thoracic 11 and 12 vertebra, paroxysmal atrial fibrillation, glaucoma, unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, unspecified protein calorie malnutrition, displaced fracture of base of neck of left femur, presence of left artificial hip joint, and osteoarthritis. Review of resident #11's January 2025 Physician's Orders revealed an order dated 07/21/2024 for quarter side rails on each side of bed up at all times as enabler in turning/repositioning. Review of resident #11's Significant Change/5 day Minimum Data Set (MDS) assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews, the facility failed to ensure residents were assessed for the risk of entrapment from bed rails prior to installation for 3 (#11, #15, and #20) of 4 (#11, #15, #20, and #29)residents reviewed for accident hazards. Findings: Review of the facility's Bed Rails and Non-Restraint Measures Policy and Procedures revised date 10/11/2024 revealed: Intent: Prior to the installation of bed rails, ____ _____ Nursing Home will attempt to use alternatives. When alternatives are not adequate to meet the resident's needs, the resident will be assessed for the use of bed rails: which includes a review of risks including entrapment; and informed consent is obtained from the resident or if applicable, the resident representative. Resident #15 Review of resident #15's record revealed an admission date of 09/22/2021 with diagnoses including chronic systolic (congestive) heart failure, hypoxemia, moderate protein-calorie malnutrition, major depressive disorder, dementia in other…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #33 Review of the medical record revealed resident #33 was admitted to the facility on [DATE] with diagnoses including in part, Type 2 diabetes with foot ulcer, cerebral vascular disease, left side,peripheral vascular disease, hemiplegia following cerebral infarction. Review of the December 2023 physician's orders revealed in part, the following orders dated 09/29/2023 for accu checks with meals and at bedtime and Humalog 100 unit/milliliter vial per sliding scale. Further review of the Humalog order revealed sliding scale insulin as 151-200 mg/dl (Milligrams per deciliter) =3 units, 201-250 mg/dl=6 units, 251-300 mg/dl=8 units, 301-350=12 units, 351-400 mg/dl=16 units, and greater than 400=20 units. Review of the November 2023 MAR (Medication Administration Record) revealed resident #33 had blood glucose levels of 441 mg/dl on the date of 11/10/2023 at 6:00 a.m., 581 mg/dl on the date of 11/17/2023 at 6:00 a.m. Review of the December 2023 physician's orders revealed there was no documented evidence of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to ensure drugs and biologicals were stored and labeled properly in accordance with currently accepted professional principles. The facility failed to have multiple use medications and biologicals labeled with the date of opening and stored per professional standards. Findings: On 12/11/2023 at 8:30 a.m., an observation of the Medication Cart A revealed there was one Novolog FlexPen and one Levemir FlexPen. Further observation revealed the FlexPens had been opened and were not labeled with an open date. S5LPN (Licensed Practical Nurse) was present during the observations. S5LPN confirmed the Novolog and Levemir FlexPens (Pre-Filled Insulin Pens) were currently being used for resident #3. She further confirmed they had not been labeled with an opened date. On 12/11/2023 at 12/11/2023 at 8:45 a.m., an observation of the Medication Cart B revealed there were four individual Humalog KwinPens (Pre-Filled Insulin Syringes). Further observation revealed they had been opened and were not labeled with an opened date. S4LPN was present…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the provider failed to ensure each resident's medication regimen was free from unnecessary medications for 1 (#17) of 5 (#11, 14, 17, 26 and 33) residents reviewed for unnecessary medications. The facility failed to have documented evidence of parameters or justification for resident #17's as needed medications administered. Findings: Review of the medical record for sampled resident #17 revealed an admission date of 01/30/2023 with diagnoses including insomnia, hypertension, hyperlipidemia, pain, hypothyroidism, hypokalemia, and heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment for daily decision making and required assistance with activities of daily living. Review of the current care plan revealed resident #17 was at risk for cardiovascular complications related to diagnoses of hypertension and cardiomyopathy. Further review of the care plan revealed the interventions were to obtain and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.