Mala Strana Health Care, LLC

In the surveyor’s words

From the most serious findings on record at Mala Strana Health Care, LLC, in the surveyor’s own words.

• Actual harm, isolatedF689May 21, 2025

  Based on observation, interview and document review, the facility failed to ensure a transfer belt was used to assist with a safe transfer for 1 of 2 residents (R30) reviewed for falls. This resulted in actual harm for R1 who fell when being transferred without a transfer belt, which resulted in a fall with a pelvic fracture. This deficient practice is being cited at past non-compliance related to corrective action taken prior to survey to ensure proper use of transfer belt prior to the survey. […]

• No harm, potential for more than minimal, widespreadF761Dec 29, 2021

  Based on observations, interviews, and policy review, the facility failed to ensure that two of four medication carts were kept locked and under direct observation of authorized staff in areas where residents and visitors could access the medications. This deficient practice had the potential to affect all residents who resided at the facility. Findings include: Review of the facility policy Medication Storage in the Facility, revised January 2018 and initialed as revised 12/27/21 by the DON, revealed that the policy did not specifically state that the medication carts should be locked; however, under the controlled substance section the policy stated that medications . are subject to special handling, storage, disposal, and recordkeeping . […]

• No harm, potential for more than minimal, isolatedF550Aug 6, 2025

  Based on observation, interview, and document review, the facility failed to ensure morning cares were provided in a dignified, courteous manner to prevent complication (i.e., frustration, misunderstanding) for 1 of 1 residents (R1) reviewed who expressed staff had been rough with her during provision of care. Findings include: R1's admission Minimum Data Set (MDS), dated [DATE], identified R1 had severe cognitive impairment but demonstrated no delusional thinking during the review period. A submitted Incident Report Summary (i.e., FRI), dated 8/4/25, identified an incident had happened on 8/3/25 where R1 had expressed nursing assistant (NA)-A and NA-B were rough when getting her out of bed in the morning. […]

• No harm, potential for more than minimal, isolatedF609Aug 6, 2025

  Based on interview and document review, the facility failed to ensure an allegation of potential verbal abuse (i.e., mocking, demeaning) was reported to the administrator and, if needed, the state agency (SA) in a timely manner for 1 of 3 residents (R1) reviewed during the abbreviated survey. Findings include: R1's admission Minimum Data Set (MDS), dated [DATE], identified R1 had severe cognitive impairment but demonstrated no delusional thinking during the review period. A submitted Incident Report Summary (i.e., FRI), dated 8/4/25, identified an incident had happened on 8/3/25 where R1 had expressed nursing assistant (NA)-A and NA-B were rough when getting her out of bed in the morning. […]

• No harm, potential for more than minimal, isolatedF580May 21, 2025

  Based on observation, interview, and document review the facility failed to notify the provider, family/resident representative, and hospice of bruising for 1 of 1 resident (R2) reviewed for skin. Findings include: R2's significant change in status Minimum Data Set (MDS) assessment dated [DATE], indicated R2 had severe cognitive impairment, dependent on staff for toileting, dressing, personal hygiene, and transfers, utilized a wheelchair, and diagnoses included arthritis, abnormalities of gait and mobility, and hospice care. […]