Maryville

In the surveyor’s words

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

• Immediate jeopardy, patternF636Jan 31, 2023

  Based on interview and record review it was determined the facility failed to complete admission and annual MDSes, for 4 of 9 sampled residents (#s 1, 2, 3 and 9) reviewed for MDS. There were an additional 26 non-sampled residents with incomplete admission or annual MDSes. This failure was determined to be an immediate jeopardy situation because it put residents at risk for unmanaged medications, side effects from medications, skin conditions, and unknown needs that were never identified or addressed, which could have led to permanent injury, severe infection, and unknown potential harm due to the lack of comprehensive assessment. Findings include: 1. […]

• Immediate jeopardy, isolatedF689Dec 18, 2023

  Based on observation, interview and record review it was determined the facility failed to assess elopement risk and provide services to prevent elopement for 1 of 3 sampled residents (#272) reviewed for elopment. This failure resulted in an immediate jeopardy situation when the facility failed to implement services to prevent elopement which resulted in Resident 272's elopment from the facility. Findings include: Resident 272 admitted on [DATE] with diagnoses including severe vascular dementia. […]

• Actual harm, isolatedF689Mar 20, 2024

  Based on interview and record review it was determined the facility failed to ensure the plan of care was followed to provide care-planned assistance to prevent a fall for 1 of 3 sampled residents (#3) reviewed for falls. This resulted in Resident 3's hospitalization with leg fracture and surgical repair. Findings include: Resident 3 admitted to the facility in 2023 with diagnoses including a history of falls. The 11/16/23 Care Plan indicated Resident 3 was at risk for falls related to impaired mobility. Interventions included providing a safe environment, including personal items within reach. The Care Plan also indicated Resident 3 required one-person assistance with bathing. […]

• Actual harm, isolatedF684Dec 18, 2023

  Based on interview and record review it was determined the facility failed to prevent the development of moisture associated skin damage (MASD) and follow physician orders for 2 of 3 sampled residents (#s 322 and 372) reviewed for skin conditions and pain management. This failure resulted in Resident 372 developing MASD and placed residents at risk for increased pain. Findings include: 1. Resident 372 was admitted to the facility in 2018 with diagnoses including heart failure. […]

• Actual harm, isolatedF689Aug 17, 2023

  Based on interview and record review it was determined the facility failed to follow resident care plans related to transfers for 3 of 7 sampled residents (#s 1, 2 and 24) reviewed for safety and transfers. This resulted in orthopedic fractures and placed all residents at risk for physical injury. Findings include: Resident 1 was admitted to the facility in 2022 with diagnoses including hypertension, lymphedema, and reduced mobility. The Admission MDS dated [DATE] indicated Resident 1 required two-person extensive physical assistance for transfers. Resident 1's Care Plan dated 8/30/22 identified Resident 1 to be at risk for falls due to decreased mobility and weakness. Interventions on the care plan included two person mechanical lift assistance for transfers. […]