Marymount Manor

In the surveyor’s words

From the most serious findings on record at Marymount Manor, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Aug 5, 2026

  Based on interview and record review, the facility failed to ensure residents with pressure ulcers (injuries to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction) received assessment, care, and treatment in accordance with their policy for one resident (Resident #1) who developed a new pressure ulcer at the facility. On 04/05/26, staff identified an open area to the resident's gluteal fold. Staff failed to document physician orders for barrier cream on the resident's treatment administration record (TAR) and failed to administer the treatment. Staff failed to complete skin assessments on a weekly basis, as ordered by the physician. […]

• Immediate jeopardy, isolatedF684Dec 18, 2023

  Based on interview and record review, the facility failed to ensure physician orders were followed when a resident (Resident #1) experienced a change in condition. Staff received orders for intravenous (IV) fluids on [DATE] due to abnormal blood chemistry. Staff did not administer the ordered IV fluids. The facility also did not administer an additional ordered fluid intake of 240 milliliters three times a shift (shifts were 12 hours) ordered to be administered for three days or obtain ordered vital signs every shift for three days. The staff did not notify the resident's physician or nurse management of the inability to administer the IV fluids. As a result, the resident continued to decline during the night. […]

• Immediate jeopardy, isolatedF689Sep 22, 2021

  Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents by failing to identify risks and hazards, evaluating them and implementing interventions for one resident who fell from an elevated bed resulting in his/her death (Resident #1), monitoring two residents at risk for elopement and implementing interventions to address wandering (Residents #2 and #14). The sample size was 15. The census was 63. The Chief Financial Officer was notified on [DATE] at 5:00 P.M., of an immediate jeopardy (IJ) which began on [DATE]. […]

• Actual harm, isolatedF686Dec 18, 2023

  Based on interview and record review, the facility failed to follow acceptable standards of nursing practice, when staff failed to assess Resident #1's skin and document or report changes in the resident's skin condition to the physician. The resident was at risk to develop skin impairment. The resident admitted to the hospital on [DATE] and was observed with an untreated wound to the sacrum (tailbone) and an additional area to the right buttock. The facility failed to have a system in place to ensure skin assessments were being performed by licensed nursing staff, to detect changes in residents' skin so prompt care and treatment could begin. The sample size was seven. […]

• Actual harm, isolatedF697Dec 18, 2023

  Based on observation, interview and record review, the facility failed to ensure scheduled pain medication was available and/or administered as ordered for one of 7 sampled residents (Resident #4). The facility failed to assess and monitor the resident for pain, notify the resident's physician when the pain medication was not delivered, and to notify the physician of increased pain. This resulted in the resident, with a history of a compression fracture in a bone in the spinal column, to experience increased pain, causing the resident to cry, have difficulty sleeping, and limiting his/her desire to move. […]