Every finding on record at Maryfield Nursing Home

Based on record review and staff interviews, the facility failed to develop an individualized comprehensive care plan in the areas of anticoagulant (blood thinner medication) use (Resident #58 and Resident #59) and in the area of communication (Resident #1, Resident #103, Resident #107) for 5 of 22 residents whose comprehensive care plans were reviewed. The findings included: 1. Resident #58 was admitted to the facility on [DATE] with diagnoses that included fracture of other parts of the pelvis and atrial fibrillation. A review of Resident #58's physician orders revealed an order dated 6/11/25 for Eliquis (an anticoagulant medication) 5 milligrams, one tablet by mouth twice a day for atrial fibrillation. A review of Resident #58's baseline care plan dated 6/12/25 indicated Resident #58 was at risk for bleeding due to anticoagulant medication use. A review of Resident #58's admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #58 was cognitively intact and was coded to have received an anticoagulant medication. A review of Resident #58's comprehensive care plan dated 6/20/25, last revised 2/26/26, revealed the care plan did not carry over the baseline care plan intervention of Resident #58 being at risk for bleeding due to the use of anticoagulant medication. An interview was conducted with Nurse Mentor #1 on 4/1/26 at 10:05 AM. She indicated she completed the care plan for Resident #58, and the care plan did not have a focus area for the use of anticoagulant medication and that it was an oversight. The Director of Nursing was interviewed on 4/1/26 at 10:17 AM and stated that Resident #58's care plan should have included the use of anticoagulant medication and felt this was missed by Nurse Mentor #1 due to an oversight. 2. Resident #59 was admitted to the facility on [DATE] with a diagnosis that included long term use of anticoagulants, unspecified atrial fibrillation, chronic systolic (congestive) heart failure, hypertensive heart and chronic kidney disease. Review of Resident #59 medication administration record (MAR) for the months from August 2025 through March 2026 revealed Resident #59 was administered Eliquis (blood thinner) 5 milligrams (mg) two times a day. An annual Minimum Data Set (MDS) dated [DATE] and quarterly assessment dated [DATE] revealed Resident #59 was moderately cognitively impaired and prescribed an anticoagulant with a diagnosis of heart failure. A medical record review revealed Resident # 59's care plan dated 2/9/2026 did not include a care plan with interventions or goals for the use of Eliquis. An interview with Nurse Mentor #2 was completed 4/1/26 at 4:11 PM. It was confirmed that Resident #59 was currently taking Eliquis 5 mg. She confirmed that she was responsible for completing Resident #59 care plan and she did not include Eliquis in the care plan. Nurse Mentor #2 stated that Eliquis, being a high-risk medication, should be on the care plan and was unable to explain why it was not included. An interview on 4/1/2026 at 4:40 PM with the Director of Nursing (DON) revealed Resident #59's use of an anticoagulant should have been included in the care plan. The care plan should include monitoring for high-risk medications and interventions. The DON was unable to explain why this was not included on Resident #59's care plan. The Administrator was interviewed on 4/1/2026 at 5:25 PM and she stated she expected any high-risk medication such as Eliquis to be included on the resident's care plan. The Administrator was unable to explain why Resident #59 did not have Eliquis included on her care plan. 3. Resident #1 was admitted to the facility on [DATE] with a diagnosis of congestive heart failure and respiratory failure. A review of Resident #1's Nursing admission assessment dated [DATE] revealed Resident #1 was hard of hearing in the left and right ear and required hearing aids to both ears. A review of Resident #1's baseline care plan dated 2/2/26 indicated that Resident #1 had impaired hearing in both ears and required hearing aids. The baseline care plan further indicated Resident #1 would be responsible for keeping up with her hearing aids. A review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed she had moderate cognitive impairment. The MDS further indicated Resident #1 had adequate hearing with the use of hearing aids, with the ability to be understood by others, and the ability to understand others. Review of Resident #1's comprehensive care plan dated 2/15/26 revealed Resident #1 had a history of falls and required moderate to extensive assistance with activities of daily living. There were no care areas or interventions related to communication. An interview and observation were conducted on 3/30/26 at 11:45 am with Resident #1. The surveyor had to move close and speak loudly within 12 inches of Resident #1's left ear to ask questions. Resident #1 reported she could not hear good and needed her hearing aids that were on her nightstand. The hearing aids were located on the opposite side of the room on Resident #1's nightstand and the resident was not able to get up independently to get them. The surveyor informed Resident #1 she would get someone to assist her with her hearing aids at that time. An interview and observation were conducted on 4/1/26 at 2:28 pm with Resident #1 that revealed she was wearing hearing aids and was able to hear the surveyor. An interview and observation conducted on 4/2/26 at 8:30 am with Resident #1 revealed hearing aids were not placed in both ears. She indicated she did have a hard time hearing staff if she was not wearing her hearing aids. The hearing aids were out of reach at the time of the interview, and the resident was not able to get up independently to get them. An interview was conducted on 4/2/26 at 8:42 am with the MDS Coordinator who revealed she was responsible for implementing resident care plans and confirmed she had completed Resident #1's comprehensive care plan dated 2/15/26. She further indicated that if a resident was able to hear while wearing hearing aids, she did not include it on the comprehensive care plan. An interview was conducted on 4/2/26 at 8:55 am with Nurse Aide (NA) #1 who revealed if Resident #1 was not wearing hearing aids, she had a hard time hearing. NA #1 stated he knew about Resident #1's hearing aids because she told him she needed them to hear. He explained resident needs were listed on a board in their room. NA #1 indicated he was responsible for putting in Resident #1's hearing aids. An observation made on 4/2/26 at 9:05 am of the board in Resident #1's room revealed no information related to hearing aids. An interview was conducted on 4/2/26 at 9:20 am with Nurse #1 who revealed Resident #1 could hear if she was wearing hearing aids and if he was in close contact. He further indicated Resident #1 may not her you if you were across the room or not facing her directly. An interview was conducted with Director of Nursing (DON) on 4/2/26 at 3:35 pm who indicated if a resident was alert and oriented, she would not expect impaired hearing to be included in a regular care plan. She confirmed that the MDS Coordinator was responsible for care plans. The DON stated hearing was discussed during standup meetings in the morning. That was how staff were made aware of care areas outside of care plans. An interview was conducted on 4/2/26 at 4:11 pm with the Administrator and Transitional Rehabilitation (Rehab) Director. The Administrator indicated she would not expect Resident #1's comprehensive care plan to include impaired hearing if the baseline care plan indicated she would be responsible for keeping up with her hearing aids. She stated that the baseline care plan outlines the residents' care, and she would expect it to be completed within 48 hours. The Transitional Rehab Director indicated that they have a stand-up meeting at 9:30 am which included the MDS Coordinator, Social Worker, Transitional Rehab Mentor, and the DON. If there were any issues regarding hearing aids, the nurse would notify the staff at that time. 4. Resident #107 was admitted to the facility on [DATE] with a diagnosis of heart disease and surgical aftercare for right knee. A review of Resident #107's Nursing admission assessment dated [DATE] revealed Resident #107 was hard of hearing in the left and right ear and required hearing aids to both ears. A review of Resident #107's baseline care plan dated 02/26/26 indicated that Resident #107 had impaired hearing in both ears. There was no documentation if the resident required hearing aids on the baseline care plan. A review of Resident #107's MDS dated [DATE] revealed Resident #107 was cognitively intact. The MDS further indicated Resident #107 had adequate hearing with the use of hearing aids, with the ability to be understood by others understood, and the ability to understand others. Review of Resident #107's comprehensive care plan dated 3/12/26 revealed no care areas or interventions related to communication. An interview was conducted on 4/2/26 at 8:42 am with the MDS Coordinator who revealed she was responsible for implementing resident care plans and confirmed she had completed Resident #107's comprehensive care plan dated 3/12/26. She further indicated that if a resident was able to hear while wearing hearing aids, she did not include it on the comprehensive care plan. An interview was conducted with Director of Nursing (DON) on 4/2/26 at 3:35 pm who indicated if a resident was alert and oriented, she would not expect impaired hearing to be included in a regular care plan. She confirmed that the MDS Coordinator was responsible for care plans. The DON stated hearing was discussed during standup meetings in the morning. That was how staff were made aware of care areas outside of care plans. An interview was conducted on 4/2/26 at 4:11 pm with the Administrator and Transitional Rehab Director. The Administrator indicated she would expect Resident #107's comprehensive care plan to include impaired hearing if the base line care plan did not indicate he would be responsible for keeping up with his hearing aids. She stated that the baseline care plan outlines the residents' care needs. The Transitional Rehab Director added that they have a standup meeting at 9:30 am which included the MDS Coordinator, Social Worker, Transitional Rehab Mentor, and the DON. If there were any issues regarding hearing aids, the nurse would notify the staff at that time. 5. Resident #103 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease. A review of Resident #103's Nursing admission assessment dated [DATE] revealed Resident #103 was hard of hearing in the left and right ear and required hearing aids to both ears. A review of Resident #103's baseline care plan dated 3/14/26 indicated that Resident #103 had impaired hearing in both ears. There was no documentation if the resident required hearing aids on the baseline care plan. A review of Resident #103's MDS assessment dated [DATE] revealed Resident #103 had moderate cognitive impairment. The MDS further indicated Resident #103 had minimal difficulty with hearing, with the ability to be understood by others, and the ability to understand others. Hearing Aide use was not indicated on the MDS. Review of Resident #103 comprehensive care plan dated 3/25/26 revealed no care areas or interventions related to communication. A review of Resident #103's Care Area Assessment (CCA) summary revealed it was completed on 3/26/26 by the MDS Coordinator. Further review revealed the area of communication was a triggered care area due to some hearing loss, even with hearing aids used. It was indicated in the CAA summary that communication would be addressed in the care plan. An interview was conducted on 4/2/26 at 8:42 am with the MDS Coordinator who revealed she was responsible for implementing resident care plans and confirmed she had completed Resident #103's comprehensive care plan. She further indicated that if a resident was able to hear while wearing hearing aids, she did not include it on the comprehensive care plan. An interview was conducted with Director of Nursing (DO)N on 4/2/26 at 3:35 pm who indicated if a resident was alert and oriented, she would not expect impaired hearing to be included in a regular care plan. She confirmed that the MDS Coordinator was responsible for care plans. The DON stated hearing was discussed during standup meetings in the morning. That was how staff were made aware of care areas outside of care plans. An interview was conducted on 4/2/26 at 4:11 pm with the Administrator and Transitional Rehab Director. Resident #103 was discussed at that time. The Administrator indicated she would expect Resident #103's comprehensive care plan to include impaired hearing if the base line care plan did not indicate he would be responsible for keeping up with his hearing aids. She stated that the baseline care plan outlines the residents' care needs. The Transitional Rehab Director added that they have a standup meeting at 9:30 am which included the MDS Coordinator, Social Worker, Transitional Rehab Mentor, and the DON. If there were any issues regarding hearing aids, the nurse would notify the staff at that time.

Based on record review and staff interviews, the facility failed to submit accurate payroll data on the Payroll Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) related to Registered Nurse (RN) hours and licensed nursing coverage 24-hours per day. This was reviewed for 1 of 3 quarters for sufficient nurse staffing (Quarter 3-April 1- June 30, 2024). Findings included: Review of the PBJ for Fiscal Year Quarter 3 2024 (April 1 through June 30) revealed there were no Registered Nurse (RN) hours and no licensed nursing coverage for the entire month of June 2024. Review of the Posted Daily Nursing Staffing Forms, Daily Staffing Sheet, and the nursing staff time detail reports for June 2024 revealed there was a RN on site for at least 8 hours a day every 24 hours and there was licensed nursing coverage at the facility 24 hours a day. During an interview on 1/29/25 at 11:27 am with the Payroll Manager, she stated she had been in her position for 5 years and had input data into the PBJ quarterly regularly with no issues. She stated she did not recall receiving any errors or doing anything different than she normally did and was unsure why the PBJ would read that there was no RNs or licensed nursing coverage for the entire month of June during Quarter 3 2024 (April 1-June 30) period. During a follow-up interview on 1/29/25 at 3:44 with the Payroll Manager, she stated she recalled receiving a rejection error after inputting data on the deadline of 8/14/24 at 5:48 pm. After researching and opening a ticket with CMS it was determined that one employee's hours had been entered incorrectly, and that issue was corrected. CMS acknowledged the employee hours were corrected and the ticket was closed by CMS on 8/21/24 at 2:00 pm. CMS acknowledged the employee hours correction and then closed the ticket. The Payroll Manager reported she was not aware of the missing hours for June until the time of the interview.

Based on staff interview and record review, the facility's grievance policy failed to include the business address and email of the grievance official, the contact information of independent entities with whom grievances may be filed, ensuring that written grievance decisions meets documentation requirements, taking corrective action in accordance with State law if the grievance is confirmed by the facility or an outside entity having jurisdiction and maintaining evidence of the result of all grievances for no less than three years. Findings included: A review of the employee handbook policy revised 11/2/2017 and titled Supporting the Right of Residents to Voice Grievances was provided by the Administrator on 8/29/18 at 11:00 AM. The policy stated, Residents, their legal representative, and family have the right to express a grievance or complaint about care and services provided by this community. They may also do so anonymously. Each grievance or complaint is to be handled with respect and in a timely manner. Further review of the policy revealed the following elements: 1. It is the responsibility of all employees within the community to listen respectfully when a resident or family member expresses a concern. 2. Residents and families are encouraged to bring concerns about the operation of the household to the household team. 3. The employee who takes the complaint should, orally or in writing, notify household leadership including the household coordinator and nurse mentor and/or Vice President of Health Services, Director of Nursing or Assistant Healthcare Administrator and Grievance Officer. 4. The leader notified of the complaint will notify and/or work with the Assistant Administrator/Grievance Officer (name and phone number were listed) who will be responsible for the completion of the remainder of the grievance process including: a. leading the investigation while maintaining confidentiality, b. issuing official decisions to the resident, c. report and coordinate with state and federal agencies, d. prevent further violations while the investigations are in process, e. complete all documentation, f. meeting all applicable state and federal laws and regulations. 5. It is expected that all employees of the household and community will be open to self-examination and be sensitive to the perspective of residents and their families. A review of the facility's grievance policy revealed it did not include the business address and email of the grievance official or the contact information of independent entities with whom grievances may be filed. The grievance policy also did not include information that ensured written grievance decisions met documentation requirements, how corrective action would be implemented in accordance with State law if the grievance was confirmed by the facility or an outside entity that had jurisdiction or how the facility maintained evidence of the result of all grievances for no less than three years. On 8/30/18 at 11:54 AM an interview was completed with the Administrator. She stated the grievance policy was included in the staff handbook. She said that although the policy had not included all the required elements outlined in the regulation the facility maintained the intent of the regulation. The Administrator reported the facility had provided information to residents and families on how to file grievances. She said information about the Ombudsman and State Agency were posted in the facility.