Continuing Care At Maris Grove

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, facility policy review, clinical records review, and interviews with staff and residents, it was determined that the facility failed to follow the care plan for one of the three residents reviewed (Resident 1). Findings: A review of the facility's policy titled Care/Service Plans, last revised in May 2021, it revealed The interim care plan will reflect resident's goals and include interventions that address his or her current needs in a language and format that resident and /or representative, if applicable, understand. The policy also indicated The care plan will include healthcare information necessary to care for a resident including Services and treatments to be administered by the community or personnel acting on behalf of the community. A review of Resident 1's admission assessment revealed the resident was admitted to the facility on [DATE], with a diagnosis of Inclusion Body Myositis (IBM- a degenerative, inflammatory disease that causes slow, progressive muscle weakness 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and Staff interview, the facility failed to develop and implement a baseline care plan for each resident that includes the minimum healthcare information to properly care for a resident for one out of 15 residents reviewed (Resident 45). Findings include:A review of facility policy Care/Service Plans, dated [DATE], indicates that each guest/resident will have an individualized Care/Service plan developed. Care/Service Plans will include guest/resident preferences, strengths, routines, personal and cultural preferences and choices as well as clinical needs.Review of Resident 45's PASRR Level I (Pennsylvania Preadmission Screening Resident Review, a screening tool to identify those with serious mental illness or intellectual and developmental disabilities to ensure they receive appropriate care) completed [DATE] revealed that Resident 45 had a positive screen for a PASRR Level II evaluation (an evaluation that ensures individuals are not inappropriately placed in nursing homes and that their…

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 a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to ensure physicians' orders were followed and bowel movement was appropriately monitored and addressed for two out of 15 residents reviewed (Residents 29 and 54).Findings: A review of the facility's policy titled Bowel Monitoring Exception Report Tutorial Bowel Protocol, updated on March 2022 revealed the following: All residents upon admission will be reviewed by provider to determine appropriate bowel regimen; 11-7 shift nurse to pull bowel exception report for all residents on designated neighborhood from last 3 days (9 shifts); 11-7 nurse to hand off to 7-3 nurse those residents who have not had a BM (bowel movement) documented in the last 3 days/9shifts; PRN (as needed) bowel regimen is administered to resident; and Resident will continue to be monitored until effectiveness is achieved. Review of Resident 29's nursing progress notes dated January 9, 2026, at 11:32 a.m., revealed the resident was a new admit with a diagnosis of falls and right…

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 Staff interview, observation and record review, the facility failed to administer parenteral fluids in accordance with physician orders for one out of 15 resident reviewed (Resident 26).Findings include:Review of Resident 26's admission record revealed they were admitted on [DATE], from the hospital after oral surgery with a diagnosis of acute hematogenous osteomyelitis (a bone infection that originates from bacteria traveling through the bloodstream) and sepsis (an illness that occurs when an infection triggers an extreme immune response in the body). Resident 26 was admitted with a double-lumen PICC (a peripherally inserted central catheter with two lines that allows the provider to deliver more than one therapy directly into the blood stream) to the right chest wall.Facility policy Central Vascular Access Device (CVAD) Dressing Change dated January 15, 2004, states: 1. Perform sterile dressing changes using Standard-ANTT (Aseptic Non Touch Technique, a standardized approach to procedures aimed at…

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 clinical record reviews, staff interviews, and facility policy reviews, it was determined that the facility failed to implement the comprehensive care plan approaches to prevent accidents for one of eight residents reviewed. (Resident 208) Findings include: Review of facility policy Care/Service Plans, review date May 2021, indicated each resident will have an individualized care/service plan developed. Care/service plans will include resident preferences, strengths, routines, personal and cultural preferences and choices as well as clinical needs. All interdisciplinary team members will document any updates/changes on care plan copy in the guest/resident suite/apartment/designated accessible location and review update with designated care associate. Review of Resident 208's admission record indicated he/she was admitted to the facility on [DATE]. Review of Resident 208's admission record indicated diagnoses including but not limited to fracture of the lower end of left femur (hip fracture), iron…

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 upon clinical record review, it was determined the facility failed to complete discharge summary on the day of planned discharge for one of three residents reviewed (Resident 45). Findings include: Review of Resident 45's clinical record revealed Resident 45 was admitted to the facility on [DATE], and was discharged to home on March 3, 2025. Review of Resident 45's clinical record failed to reveal a discharge summary completed on March 3, 2024, the day of a planned discharge. The above information was conveyed to the Nursing Home Administrator on March 14, 2025, at 1:38 p.m. 28 Pa. Code 211.5(f) Clinical Records

Based on clinical records review and staff interview, it was determined that the facility failed to ensure the physician's order regarding medication was followed for one of the 16 residents reviewed (Resident 12). Findings include: A review of Resident 12's physician order dated May 29, 2024, revealed an order for Lorazepam (A medication to treat anxiety) 2mg/ml Give 1 mg (0.5ml) every 2 hours as needed for Anxiety sublingually (Medication administered under the tongue). A review of Resident 12's November 2024, Medication Administration records and controlled substance declining sheet revealed that instead of 0.5 ml, Resident 12 was administered 0.25 ml of Lorazepam on the following dates: November 2, 2024, at 2:53 p.m., November 7, 2024, at 2:39 p.m., November 9, 2024, at 3:50 p.m., and November 14, 2024, at 1:00 a.m. An interview with the Director of Nursing conducted on March 14, 2025, at 10:40 a.m., confirmed Resident 12's physician's order for as-needed Lorazepam was not followed on the dates listed above. The facility failed to ensure Resident 12's as-needed Lorazepam order…

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 clinical records review and staff interviews, it was determined that the facility failed to follow a wound specialist's recommendation for wound treatment for one of the two residents reviewed (Resident 25). Findings include: Clinical records review revealed Resident 25 was admitted to the facility on [DATE], for diagnosis of Congestive Heart Failure (CHF-A weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs). A review of the skin assessment revealed Resident 25 was admitted to the facility with a Stage 2 Pressure Ulcer (Partial-thickness skin loss with exposed dermis) to the sacrum (The triangular bone just below the lumbar vertebrae). Wound treatment was made and followed. A review of the wound consult dated February 3, 2025, revealed Resident 25's sacral wound progressed into an Unstageable Pressure Ulcer (Obscured full-thickness skin and tissue loss) measuring 1.5 x 0.7 cm with 100% slough (is non-viable yellow, tan, gray, green or brown tissue; usually…

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 facility policy review, clinical records review, and staff interviews, it was determined that the facility failed to ensure appropriate monitoring of weight and food intake was done and that significant weight change was timely addressed for one of 16 residents reviewed (Resident 20). Findings include: A review of the facility policy titled Weight Management, version June 2021, revealed residents would have their weight obtained on admission, re-admission, and monthly or at a frequency determined by the interdisciplinary team or provided. Residents with a weight variance equal to or greater than five pounds of five percent will be reweighed within 24 hours and weight will be entered into an EMR (Electronic Medical Record). The medical provider and responsible party will be notified of any significant change. Clinical records review revealed Resident 20's diagnosis list includes Prostate Cancer, Parkinson's Disease (A disorder of the central nervous system that affects movement, often including tremors), and Dysphagia (Difficulty swallowing). A review of Resident 20's…

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 a review of their job descriptions it was determined that the Continuing Care Administrator (CCA), and the Director of Nursing (DON) did not effectively manage the facility to ensure that CardioPulmonary Resuscitation was provided in accordance with the facility policy and procedures to residents that are a full code. Findings include: Review of the job description for the Continuing Care Administrator (CCA) revealed the essential function is responsible for ensuring compliance with all federal, state, local and facility regulations, and policies. Oversees and audits nursing services to ensure high quality nursing delivery systems. Review of the job description for the Director of Nursing (DON) revealed the responsibility of the job position is to coordinate and implement the comprehensive delivery of nursing services to all Continuing Care residents (skilled nursing, long term care, assisted living and memory care) according to Erickson's Person-Centered Approach care model and standards, professionally recognized nursing practices and local, state, and federal…

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 staff interviews it was determined that the facility failed to ensure the dignity of residents in one of the three units observed (Cardinal 2). Findings include: Observations conducted during the environmental tour of the rooms on the Cardinal 2 unit was conducted on January 29, 2024. Observation conducted in Resident 39's room on January 29, 2024, at 10:00 a.m., revealed a white paper with a typewritten note After each meal, make sure [resident's name] mouth is clean. Check for any residue on the tongue let her/him take multiple sips of water, and if possible, brush their teeth following breakfast and dinner. Thank you, [staff name] The note was posted on the wall of the room near the door visible from the hallway outside the room. Observation conducted in Resident 11's room on January 29, 2024, at 12:17 p.m., revealed a white paper with a typewritten note Toileting Needs: Dear caregivers [resident's name] frequently has bowel movement after meals, please take [resident's name] to the toilet after each meal to give her/him the opportunity to have bowel…

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 clinical record review and staff interview it was determined the facility failed to complete a discharge summary for one of three residents reviewed. (Resident 50) Findings Include: Review of resident's records revealed a progress note dated [DATE], at 2:36 am, noting the resident discharged to [NAME] Hospital at approximately 1:30 am. Resident noted to have shortness of breath, pulse ox was 56% on room air. Resident was put on O2 @ 5liters via nasal cannula. Pulse ox was up 82%. Resident was lethargic, sweaty and could not respond much when name was called. Blood sugar was 256, vital signs were unstable. Nursing supervisor called on-call doctor and resident was sent out via EMS. POA was made aware before resident was sent out to hospital. Further review of resident's record revealed a progress note dated [DATE], at 7:03 am, noting resident was being admitted to [NAME] Hospital with a diagnosis of pneumonia. It was further noted that Resident 50 never returned to the facility. Resident 50 expired in the…

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 clinical records review and staff interview, it was determined that the facility failed to ensure the physician's order regarding blood sugar was followed for one of the 17 residents reviewed (Resident 19). Findings include: A review of Resident 19's diagnosis revealed malignant neoplasm of the connective and soft tissue of the pelvis, and Hypoglycemia (low blood sugar level). A review of the physician order dated December 19, 2023, revealed an order to check Resident 19's blood sugar every four hours when awake. Call a physician if blood sugar is less than 60 or greater than 350. A review of the January 2024, Treatment Record revealed that from January 1, 2024, until January 31. 2024, Resident 19 had a blood sugar below 60 on the following days: January 3, 2024, at 12:00 a.m., 38 mg/dl; January 7, 2024, at 12:00 p.m., 44 mg/dl; January 9, 2024, at 8:00 a.m., 38mg/dl; January 10, 2024, at 4:00 p.m., 44 mg/dl; January 14, 2024, at 8:00 a.m., 38 mg/dl; January 15, 2024, at 8:00 a.m., 55 mg/dl; January 15, 2024, at 12 noon, 48 mg/dl; January 16, 2024, at 8:00 a.m., 36 mg/dl;…

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 clinical record review and staff interview, it was determined that the facility failed to ensure the pharmacy services provided medications timely for one of the 17 residents reviewed. (Resident 19). Findings include: Review of Resident 19's clinical records revealed the resident with a diagnosis of Hypoglycemia (low blood sugar). Review of Resident 19's physician orders dated January 17, 2023, revealed an order for True plus Glucose 4 gram chewable four tablets every four hours for low blood sugar. Review of Resident 19's January 2024, Medication Administration Record (MAR) revealed Resident19's glucose tablet was not administered on the following day/time: January 18, 2024, at 2:00 a.m.; January 20, 2024, at 2:00 p.m.; January 27, 2024, at 6:00 a.m., and January 27, 2024, at 10:00 a.m. REview of Resident 19's clinical records and administration notes revealed that Resident 19's glucose tablet was not administered to the resident on the above-mentioned dates/time due to awaiting pharmacy delivery of the medication. Interview with the Director of Nursing conducted on…

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.