Continuing Care at Maris Grove

In the surveyor’s words

From the most serious findings on record at Continuing Care at Maris Grove, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Feb 1, 2024

  Based on a review of established guidelines for cardiopulmonary resuscitation (CPR), the facility's policies, residents' clinical records, and staff interviews, it was determined that the facility failed to ensure that CPR was provided in accordance with established facility policy and procedure for Resident 207, creating a situation for one of six residents were placed in an Immediate Jeopardy situation related to failure to perform cardiopulmonary resuscitation. Findings include: Review of guidelines from the American Heart Association (AHA), dated 2020, revealed, the AHA urged all potential rescuers to initiate CPR unless a valid Do Not Resuscitate (DNR) order was in place; if there were obvious clinical signs of irreversible death present, including rigor mortis (stiffness of the limbs… […]

• Actual harm, isolatedF689Mar 14, 2025

  Based on review of facility documents, facility policy, clinical records, resident interview, and staff interviews, it was determined the facility failed to ensure one of eight residents reviewed was provided with adequate supervision to prevent accidents for one resident (Resident 208) which resulted in actual harm when Resident 208 fell resulting in a fracture clavicle. Findings include: Review of facility policy titled Fall Management, review date of April 2023, revealed a fall is any event resulting in the resident coming to unintentionally on the floor or other lower level but not as a result of an overwhelming external force. Each resident will be assessed using a Holistic Assessment for potential risk for falls on admission, readmission and quarterly for continuing services. […]

• Actual harm, isolatedF600Jan 29, 2021

  Based on a review of facility documentation, policy review, clinical record review, staff interviews, and observations, it was determined that the facility failed to ensure residents were free from neglect, which caused actual harm to one resident, when a nursing assistant knowingly failed to review the resident's diet orders and gave the resident a beverage that was the wrong consistency, which the resident consumed and resulted in Resident CL1's subsequent hospitalization and expiration due to aspiration pneumonia and acute hypoxic [CONDITION(S)] for one of five residents reviewed, (Resident CL1). […]

• No harm, potential for more than minimal, widespreadF812Mar 11, 2022

  Based on observations, interviews, and facility documentation review, it was determined that the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: During a follow up tour to the main kitchen on March 10, 2022, at approximately 10:15 a.m. the following issues were observed: Four shelves with six pans and hotel pans were noted to be visibly wet and stacked on top of one another. Interview with Employee E3, the executive chef, at this time confirmed the pans should have been completely dried before being stacked. Observation of stacks of clean plates located directly next to a garbage can. […]

• No harm, potential for more than minimal, patternF835Feb 1, 2024

  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. […]