Maryhill Manor

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure an allegation of abuse was reported to Nursing Home Administrator (NHA)-A or their designee for 1 resident (R) (R1) of 5 sampled residents. On 6/11/26, Certified Nursing Assistant (CNA)-C observed an incidence of verbal abuse directed toward R1 by CNA-E. The abuse was not reported to NHA-A.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 46 residents residing in the facility. The facility did not test the temperature of the sanitizing solution used in sanitizing buckets and the 3-compartment sink per manufacturer's recommendations. In addition, the facility did not monitor parts per million (PPM) of the sanitizing solution. The facility did not consistently label resident food with use-by dates and ensure timely disposal of expired items.

Inspectors wroteBased on staff interview and record review, the facility did not ensure timely transmittal of a Resident Assessment Information (RAI)/Minimum Data Set (MDS) assessment for 1 resident (R) (R23) of 14 sampled residents. The facility did not transmit a Discharge MDS assessment for R23 in a timely manner when R23 was transferred to the hospital and did not return to the facility.

Inspectors wroteBased on staff interview and record review, the facility did not accurately code Minimum Data Set (MDS) 3.0 assessments for 3 residents (R) (R58, R7, and R20) of 14 sampled residents. R58 was admitted to the facility on [DATE]. The facility did not ensure R58's name was accurately and consistently reflected on all of R58's transmitted MDS assessments. R7's Pre-admission Screening and Resident Review (PASRR) Level II (used to identify individuals with mental illness and/or intellectual or developmental disability to ensure appropriate placement), dated 1/8/25, indicated R7 had a mental illness. R7's MDS assessment, dated 3/28/25, did not indicate R7 had a mental illness. R20's MDS assessment, dated 3/11/26, indicated R20 received anticoagulant medication. R20 did not have an order for anticoagulant medication and did not receive anticoagulant medication.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide the appropriate care and treatment to prevent the development of pressure injuries and/or promote healing for 1 resident (R) (R4) of 1 sampled resident. R4 had a stage 2 pressure injury on the left buttock. During an observation of wound care, Registered Nurse (RN)-E did not remove gloves and cleanse hands appropriately. In addition, RN-E used a gloved finger to apply ointment to R4's wound.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure enhanced barrier precautions (EBP) were implemented during high-contact cares for 2 residents (R) (R1 and R4) of 2 sampled residents. R1 had an order for EBP due to open wounds. The facility did not ensure EBP was implemented for R1 during a transfer and toileting. R4 had an order for EBP due to an open wound. The facility did not ensure EBP was implemented for R4 during wound care.

Inspectors wroteBased on staff interview and record review, the facility did not notify a physician when 1 resident (R) (R2) of 4 sampled residents was physically aggressive toward another resident. R2 had a history of making threats to suffocate R1 with a pillow. On 2/20/25, R2 placed a pillow over R1's face in an attempt to quiet R2. R2's physician was not notified of the incident.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a care plan was reviewed and revised for 1 resident (R) (R2) of 4 sampled residents. R2's care plan was not updated with interventions to address aggressive behavior, resident-to-resident altercations, and the impact of loud noise on R2.

Inspectors wroteBased on staff interview and record review, the facility did not ensure confidentiality of medical records for 2 residents (R) (R4 and R5) of 5 sampled residents. Registered Nurse (RN)-D requested a copy of RN-D's personnel file after RN-D's last day of employment on 10/30/23. The information provided to RN-D contained protected health information (PHI) from R4 and R5's medical records.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. The practice had the potential to affect all 45 residents residing in the facility. Staff did not monitor and document food cooling temperatures. Staff did not serve food in a manner that protected residents from cross-contamination. Staff did not perform appropriate hand hygiene and safe food handling practices when serving food.

Inspectors wroteBased on staff interview and record review, the facility did not ensure vaccinations were administered for 1 resident (R) (R3) of 5 sampled residents. R3 was not offered the PCV20® vaccine.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the resident environment remained free from abuse for 2 residents (R) (R2 and R4) of 5 sampled residents. R2 reported to Activity Aide (AA)-D on 6/6/24 that R1 had touched R2's breast in the hallway that morning. Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B reviewed camera footage on 6/6/24, interviewed both residents, and determined the allegation did not occur. Monitoring interventions were not implemented for R1. On 6/7/24, Social Services Director (SSD)-C informed NHA-A and DON-B that SSD-C had seen R1 and R2 in the lounge after lunch on 6/6/24. NHA-A and DON-B again reviewed camera footage and determined R1 had touched R2 inappropriately on 6/6/24 at approximately 1:04 PM. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of sexual abuse was reported to the State Agency (SA) or local law enforcement in a timely manner for 2 residents (R) (R1 and R2) of 5 sampled residents. On 6/6/24, R2 told staff that R1 had touched R2 inappropriately without R2's consent. The facility did not report the allegation of sexual abuse to the SA or to local law enforcement within the accepted regulatory timeframe.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of sexual abuse was thoroughly investigated for 2 residents (R) (R1 and R2) of 5 sampled residents. On 6/6/24, R2 told staff that R1 had touched R2 inappropriately without R2's consent. The facility did not thoroughly investigate the allegation of sexual abuse before they determined the allegation did not occur and later discovered the allegation did occur.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure menu serving sizes for regular and pureed diets were followed for 42 of 42 residents residing in the facility. The facility did not follow menu serving sizes to ensure the nutritional needs of residents were met.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect 42 of 42 residents residing in the facility. The facility did not ensure time/temperature control foods were labeled with open or use-by dates. Residents' food in snack/nourishment refrigerators did not contain expiration dates to prevent the potential for foodborne illness. Staff did not wear hair restraints consistently throughout the kitchen.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not notify a physician after a change of condition for 1 Resident (R) (R31) of 15 sampled residents. The facility did not update R31's physician until two days after R1 experienced a change in condition and developed a productive cough.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not maintain an infection prevention and control program to help prevent the transmission of communicable disease and infection for 1 Resident (R) (R31) of 15 sampled residents. The facility did not implement transmission-based precautions (TBP) until two days after R31 developed a new cough. In addition, the facility did not test R31 forty eight hours after the first negative antigen COVID-19 test after R31 developed a new cough.