Mary Anna Nursing Home

Inspectors wroteBased on record reviews and interviews, the facility failed to protect the resident's right to be free from neglect for 1 (#26) of 1 sampled resident reviewed for neglect. S4CNA failed to provide and follow required safety procedures when transporting Resident #26 in the facility van. This deficient practice resulted in an Immediate Jeopardy situation on 01/06/2026 at approximately 1:30 p.m. when Resident #26 was returning from a physician appointment. S4CNA failed to properly secure Resident #26 with the restraining seatbelt in the facility van. Resident #26 verbalized to S4CNA during return transportation that she was sliding out of her wheelchair. S4CNA failed to stop the vehicle and assist Resident #26 with repositioning. S4CNA continued to drive to her personal residence and left Resident #26 alone in the van. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to provide adequate supervision and properly secure the resident with the facility van's restraining seatbelt to prevent accidents for 1 (Resident #26) of 5 sampled residents reviewed for accidents. This deficient practice resulted in an Immediate Jeopardy situation on 01/06/2026 at approximately 1:30 p.m. when S4CNA failed to properly secure Resident #26 (who was wheelchair dependent) with the transportation van's restraining seatbelt. S4CNA left Resident #26 in the transportation van unsupervised while S4CNA stopped at her personal residence. This resulted in Resident #26 slipping out of her wheelchair onto the van floor while she was unsupervised. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteResident #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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.