Snf-The Villa at Marymount

In the surveyor’s words

From the most serious findings on record at Snf-The Villa at Marymount, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Nov 8, 2023

  Based on medical record review, staff interview, power of attorney (POA) interview, resident interview, review of a Self -Reported Incident (SRI) and investigation, review of facility sign out sheets, and review of the facility policy for signing residents out, the facility failed to provide supervision and follow the facility policy for a resident signing out for a leave of absence (LOA) to ensure the whereabouts for one resident (Resident #87) who had left the facility after reporting she was leaving on a LOA. This resulted in Immediate Jeopardy and the potential for serious harm, injury or death, on 10/24/23 at approximately 4:30 P.M. […]

• Actual harm, isolatedF689Mar 13, 2025

  Based on record review, hospital record review, and interview, the facility failed to ensure Resident #16 was safely assisted with activities of daily living to prevent a fall with major injury. Actual harm occurred on 02/06/25 when Resident #16, who was comprehensively assessed and ordered to need two staff members to assist when giving personal care, received incontinence care by only one staff member, resulting in a fall, hospitalization , and fractured hip. This affected one resident (#16) of five residents reviewed for falls. The total census was 110. Findings include: Review of Resident #16's medical record revealed the resident was admitted to the facility on [DATE] and had diagnoses including multiple sclerosis, disorder of bone density, and obesity. […]

• Actual harm, isolatedF686Feb 20, 2024

  Based on closed medical record review, policy review and interview, the facility failed to provide preventive care consistent with professional standards of practice to promote healing of a pressure ulcer wound for Resident #98. This affected one (Resident #98) of three residents reviewed for pressure ulcers. The census was 97. Actual harm occurred for Resident #98 when a Stage I pressure ulcer (intact skin with a localized area of non-blanchable erythema/redness) to the resident's coccyx, which was identified on 01/10/24, was noted to have deteriorated to a deep tissue injury (intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) on 01/23/24 after the facility did not implement pressure-reducing… […]

• Actual harm, isolatedF686Nov 8, 2023

  Based observation, record review, facility policy review, staff interview, and resident interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development and deterioration of a pressure ulcer for Resident #33. Actual Harm occurred on 10/09/23 when Resident #33, who required extensive assistance from staff for bed mobility and activity of daily living care including turning and repositioning, developed an unstageable pressure ulcer to the left buttocks without being provided adequate pressure relief. Following the development of the pressure ulcer, pressure relief was not provided as ordered and the pressure ulcer was assessed to deteriorate. […]

• Actual harm, isolatedF760Apr 15, 2021

  Based on closed record review, facility policy review and interview, the facility failed to ensure Resident #743 was free from a significant medication error. This affected one resident (#743) of four residents (#48, #737, #738, and #739) reviewed for medication error. The facility census was 99. Actual harm occurred when Resident #743 was administered too much medication for muscle spasms resulting in a decrease in blood pressure, dizziness, drowsiness, and hallucinations. Resident #743 was given 8.0 milligrams (mg) of [MEDICATION(S)] instead of the 2.0 mg per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. Emergency Medical Services (EMS) arrived at the facility to transport Resident #743 to the local hospital. […]