Mary Anna Nursing Home

In the surveyor’s words

From the most serious findings on record at Mary Anna Nursing Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Mar 18, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF689Mar 18, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF656Mar 18, 2026

  Based 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. Findings:Resident # 1 Review of the record for Resident #1 revealed an admission date of 08/08/2024 with diagnoses that included type 2 diabetes mellitus with diabetic neuropathy, gastroesophageal reflux disease, vitamin D deficiency, osteoarthritis, dementia, hypertension, hyperlipidemia, and history of falling. […]

• No harm, potential for more than minimal, patternF692Mar 18, 2026

  Based 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. Findings:Review of the facility undated Policy and Procedure: Weight Loss Management revealed the following, in part:III. Definitions:Significant Weight Loss: 1 month: >5% loss of body weightIV. ProcedureC. Identification of Weight Loss:1. If a significant weight loss is identified, nursing staff must notify the dietitian, attending physician, and the responsible party within 24 hours.2. Place the resident on the facility's High Risk /Weight Management List for closer monitoring.D. […]

• No harm, potential for more than minimal, patternF726Mar 18, 2026

  Based 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. Findings:Resident #1Review of the record for Resident #1 revealed an admission date of 08/08/2024 with diagnoses that included type 2 diabetes mellitus with diabetic neuropathy, gastroesophageal reflux disease, vitamin D deficiency, osteoarthritis, dementia, hypertension, hyperlipidemia, and history of falling. […]