Maywood Acres Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop a care plan for three of three residents (Resident 49, 86 and 54) related to: 1. A pad alarm that was considered as a restraint for Residents 49 and 86 2. A diagnosis of Hepatitis C (a liver disease caused by the hepatitis C virus, which is primarily transmitted through exposure to infectious blood or body fluids that contain blood) for Resident 54. These failures had the potential for Resident 49, 86 and 54 not to receive the appropriate care and services, based on problem areas identified. Findings: 1. During an observation on 8/19/24 at 9:18 a.m. and at 9:28 a.m., in Resident 86 and Resident 49 rooms respectively (room [ROOM NUMBER] B and room [ROOM NUMBER] A). Resident 86 was observed in bed, watching TV with a pad alarm (a pressure sensitive pad positioned beneath resident attached to a control unit that emits a loud alarm) attached to a control unit on the bed. Resident 49 was observed seated on a wheelchair, with a pad alarm…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure nursing staff demonstrated competency in medication administration when: 1. A licensed vocational nurse (LVN) 1 administered the wrong laxative (medication that treats constipation) to one unsampled resident (Resident 53). 2. Blood pressure and heart rate readings were not accurately documented for one of five sampled residents (Resident 68) prior to receiving the medication Carvedilol (medication to treat heart failure and high blood pressure after a heart attack). 3. Monitoring for medication side effects and bleeding complications was not implemented for one of five sampled residents (Resident 344) receiving the medication Apixaban (medication that prevents blood clots). These failures had the potential to harm these residents as a result of unsafe medication administration. Findings: 1. During a review of Resident 53's admission Record (AR), dated 8/21/24, the AR indicated in part, Resident 53 was an [AGE] year-old male, who…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure monitoring for side effects and manifestation of behaviors was done for Mirtazapine (a drug used to treat depression) for one Resident (Resident 54). This failure had the potential for unrecognized side effects of the Mirtazapine and occurrence of manifested of behaviors. Findings: During a review of the admission Record (AR) of Resident 54, the AR indicated a diagnosis of Major Depressive Disorder (a serious mental disorder that affects how a person feels, thinks, and act). During a review of the Order Summary Report (OSR) dated 8/20/24 for Resident 54, the OSR indicated in part, Mirtazapine Oral Tablet was prescribed on 4/24/24 for Depression manifested by lack of interest in food. During a review of the Resident 54's care plans dated 5/2/24, this indicated in part, interventions monitor for occurrences of depressive behavior every shift and update MD as needed and monitor/document side effects and effectiveness every shift. During a review of Resident 54's Medication Administration Record (MAR), for the month of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure two of two sampled resident's (Resident 19, Resident 1) therapeutic mechanical soft, chopped diet order was plated correctly in the kitchen in accordance with the physician's order and facility's planned menu/diet manual. As a result, of not implementing the chopped diet safely residents were at an increased risk of choking. Findings: 1. During a concurrent observation and interview on 8/19/24 at 11:12 a.m. with Registered Dietitian (RD), Resident 19's lunch meal was plated with chopped pieces of baked chicken that appeared larger than 1/2 [half inch] in size. Resident 19's lunch meal tray ticket indicated mechanical soft, chopped, renal [diet for kidney disease] diet order. Resident 19's meal tray was observed placed on the meal delivery cart for distribution by dietary aide (DA) 3. RD was asked to remove Resident 19's meal tray from the meal delivery cart and check it for accuracy. RD observed the size of the pieces of chopped chicken, and RD stated, The chopped diet is okay. RD was asked to review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure resident's lunch was served in an attractive manner when the food items on the plate were similar color (brown) and the noodles were mushy when the food was hot held for a prolonged period of time prior to the lunch meal service. Three residents expressed dissatisfaction with the facility's food during the survey(Resident 48, Resident 43, Resident 2). As a result, hot holding food for a prolonged period of time was not a method of food preparation that conserves nutritive value or appearance. In addition, food that was served lacked a variety of color creating an unappetizing appearance and could cause less food intake and weight loss. Findings: .During a concurrent observation and interview on 8/19/24 at 08:37 a.m. with [NAME] 1 upon entrance into the kitchen to begin survey, steamtable was observed empty as breakfast meal had been completed. [NAME] 1 was observed cooking at the stove range, and [NAME] 1 stated she was preparing lunch for residents. During a concurrent observation and interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to demonstrate it notified a physician of a change in condition in a timely manner and per policy and procedure, for one of two sampled residents (Resident 1). This facility failure had the potential for emergency medical care to be delayed for Resident 1. Findings: During a review of Resident 1's Change In Condition form dated 6/7/24, indicated in part, Resident 1 had a change in condition when experiencing Hypoxia (a potentially life-threatening situation which results in low levels of oxygen in a person's tissues and cells) during PT (physical therapy). The Change In Condition form indicated this event started on 6/7/24, in the morning. The Change In Condition form indicated in part Resident (Resident 1) noted with hypoxia and diaphoresis (excessive sweating) during PT, resident (Resident 1) was fluctuating between 88%-95% RA (room air). Resident (Resident 1) moaning when transferred back to bed. The Change In Condition form indicated in part Resident 1's physician was notified at 12:00 p.m. on 6/7/24 of Resident 1's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to follow their policy and procedures pertaining to Residents going out on a leave of absence, for two of two sampled Residents (Resident 1 and Resident 2). This failure had the potential for the facility not to know where residents were going, while out on pass from the facility or when they returned. Findings: During a review of the facility's policy and procedure titled POLICY AND PROCEDURE FOR RESIDENT'S LEAVE OF ABSENCE/OUT ON PASS dated 3/13/24, indicated in part Residents before leaving the facility shall fill out the Release of Responsibility for Leave of Absence Form. This form shall record the name/signature of the person accompanying the resident. If self-responsible, resident will sign out for himself. The time the resident left the facility and the place/location the resident is going to must also be written in the form. Once the resident is back, License nurse or facility representative shall confirm that the resident came back by filling out the time they came back and by placing his/her signature. During a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure turning and repositioning as stated in the resident's care plan for one of three sampled residents (Resident 2) was documented to reflect the care plan was implemented. This failure had the potential for pressure ulcer development or skin breakage on the resident. Findings: During a review of Resident 2's admission Record, dated 5/12/22, the admission Record indicated, upon admission to the facility, Resident 2 had a diagnosis of dementia (memory loss that disrupts daily life). During a review of Resident 2's Care Plan, dated 4/20/23, the Care Plan indicated, Resident 2 had a problem with actual pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) related to right heel, with a facility intervention of Turn and repositioning (moving a resident into a different position to redistribute pressure from a particular part of the body) at least q (every) 2-3 hours . During a review of Resident 2's Wound Evaluation and Treatment Progress Notes, dated 4/13/23, 4/20/23, 4/27/23,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure the ice machine was sanitized according to manufacturer's guidelines. This failure have the potential to placed the residents at risk for gastrointestinal illnesses and other water borned illnesses. Findings: During a concurrent observation, and interview on 7/27/21, at 10:25 AM with Maintenance Supervisor (MS), in a room adjacent to the kitchen housing the facility's Ice Machine, the inside lower panel that goes over the Ice Machine bin was observed with white-colored substance and small, black-colored spots. The MS indicated the white spots were calcium deposit build-up, was unsure what the black spots were, but it can be wiped off. The MS further indicated an outside company cleans the Ice Machine and the MS was not sure when was the last time it was cleaned . The MS stated, I don't like to be in here when they spray. During a review of the facility's service agreement with the outside company, titled, Proposal, dated 8/20/19, indicated, . Scope of Work - bid price on the preventive maintenance on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure care services provided to residents met professional standards when: 1. Pain medications given for three residents (Resident 34, 51, and 414) were not documented as administered on the facility's Medication Administration Record ( MAR). 2. The pre (before) and post (after) pain assessments for two residents (Resident 34 and 51) were not documented on the Pain Assessment Flow Sheet (PAFS) after pain medication administration. These failures had the potential to unknowingly administer additional doses of pain medications to residents resulting to double dosing which is a medication error. Findings: Review of [NAME] and [NAME], 6th Edition, Mosby's Fundamentals of Nursing, page 847 in the section titled, Medication Administration indicated, After administering a medication, the nurse records it immediately on the appropriate record form. The nurse never charts a medication before administering it. Recording immediately after administration prevents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure dietary staff had the competency and skills to keep and maintained food contact surfaces were sanitized effectively. This failure had the potential to spread food borne diseases to residents and occupants of the facility. Findings: During an observation and concurrent interview with the facility's [NAME] and Assistant [NAME] (AC), on 7/28/21 at 8:50 AM, the [NAME] and AC indicated food contact surface countertops were sanitized by using a cloth soaked in sanitizer from the red bucket (red container with sanitizing solution). The [NAME] return demonstrated the sanitizing process in the prsence of the facility's Registered Dietician (RD), Dietary Services Supervisor (DSS), Department's RD and surveyor by filing up the red bucket with sanitizing solution and checking the solution concentration (parts per million -PPM) with a chemistry test strip (CTS- [NAME] QAC 2951) via a colored coded graph chart (color indicates amount of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to clean glucometers (machine used to measure blood sugar) per manufacturer's instructions for use. This failure had the potential to result in cross contamination and spreading of infectious disease to the residents. Findings: Review of the manufacturer's instructions for use titled, Maintenance, undated indicated in part . it is ARKRAY's policy to advise healthcare professionals to clean and disinfect blood glucose meters between each resident test to avoid cross contamination issues . Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe . To use a wipe, remove from container and follow product label instructions to disinfect the meter. Review of the label for wipes, Sani-Cloth Bleach Germicidal, Disposable Wipe, undated indicated in part . Bactericidal, Fungicidal, Tuberculocidal, and Virucidal in 4 minutes . Disinfects in 4 minutes . 4 minute wet time. During an observation of Med Cart 1 and a concurrent interview with licensed nurse (LN 4) on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and interview, the facility had 31 resident rooms that do not meet the required square footage of 80 square feet per resident . These rooms are: Two resident rooms: (Required 160 square footage). rooms [ROOM NUMBERS] are 148 square footage. rooms [ROOM NUMBERS] are 139 square feet. Three resident rooms with three beds occupancy: (Required 240 square footage). Rooms 3, 4, - 217 square feet. Rooms 6,7,8,9 -212 square feet. Rooms 10,11,12 -221 square feet. Rooms 14,15 -221 square feet. Rooms 16,17 -218 square feet. Rooms 20,21,22,23,24,25,26,27 -224 square feet. Rooms 28,29 -234 square feet. Rooms 30,31,32,33 -215 square feet. Findings: Observations made during initial facility tour, on 7/27/2021 thru 7/30/2021, revealed the facility had 31 residents rooms (two to three residents per room) with less square footage than the required 80 square feet per resident. Observations revealed the 31 rooms had sufficient space in each room for the provision of nursing services, placement of resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to ensure a medical physician sign the Physicians Orders for Life-Sustaining Treament (POLST) for one of 18 sampled residents (Resident 54). This failure had the potential for life sustaining orders to be not authorized or authenticated by the resident's physician which can result in the delay of medical interventions during an emergency. Findings: During a review of the clinical record for Resident 54, the POLST dated 4/7/21 was not signed by the resident's physician . The facility policy and procedure titled Physicain's and Telephone orders dated 3/2/16 indicated, physicain's orders are to be counter signed within 5 days the order was received. During and interview on 7/28/2021 at 1 PM the medical records (MR) acknowledged the document was not signed by the physician.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a discharge Minimum Data Set (MD- assessment data of resident ) was timely done for one resident (Resident 1) This facility failure had the potential to result in wrong entry to the federal data base . Findings: Review of Resident 1's overall assessment history indicated a discharge occurence . During an interview and concurrent record review with licensed nurse (LN 6) on 07/30/21, at 02:54 PM, LN 6 stated Resident 1 was discharged home on 3/25/21 and it was a planned discharge. LN 6 further stated a planned discharged assessment should be opened on the last covered day of skilled services ( physical , occupational, and nursing). Further review of the clinical record of Resident 1, no discharge assessment dated [DATE] was noted on record review. LN 6 acknowledged she missed opening and closing the discharge MDS on time.

Based on interview and record review the facility failed to ensure a resident's careplan ( planned measures, interventions to direct care) was updated after a fall occurence for one out of 18 sampled residents (Resident 54). This failure has the potential for interventions and measures in place that won't be effective to prevent a fall recurrence . Findings: Review of the clinical record for Resident 54 indicated the resident had a fall incident on 6/7/21. The careplan in place for fall showed no review of interventions to address the fall on 6/7/21. During an interview on 7/27/2021 at 4 PM , licensed nurse (LN7) indicated she was on duty when the resident fell on 6/7/21. LN7 acknowledged Resident 54's care plan was not updated after the fall. The facility policy and procedure titled Fall Incidents Management and Prevention dated 4/22/15 indicates a care plan will be initiated or updated with interventions to prevent further falls.

Based on observation, interview, and record review, the facility failed to ensure consumption of therapeutic (to cure or restore to health) nutritional supplements was accurately documented and monitored in two of 18 sampled residents (Resident 6 and Resident 18). This failure had the potential to ineffectively evaluate and delay timely revision of interventions needed to meet residents' nutrition needs. Findings: 1. During a review of Resident 6's admission Record, with printed date of 7/27/21, indicated an admission date of 1/18/19, with medical diagnoses, including, Unspecified Sequelae of Other Cerebrovascular Disease (a range of conditions that affect the blood flow through the brain), Difficulty in Walking, Abnormal Posture, Essential Hypertension (high blood pressure), Allergic Rhinitis (an allergic reaction that causes sneezing, itchy and stuffy nose, and sore throat), Dry Eye Syndrome (a condition where the eyes don't make enough tears), History of Falling, and Personal History of COVID-19 (a severe, respiratory infection caused by the Corona Virus 2). During a review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and recored review the facility failed to ensure the use of PRN (as needed) psychotropic (medication that can affect a person's mental state) medication does not exceed 14 days for 2 out of 18 sampled residents ( Residents 23 and 60). This facility failure had the potential for unneccessary use of medication with no evaluation and assessment of need. Findings: During a review of the clinical record for Resident 23 indicated a physician order for PRN Temazepam 15 mg. one capsule at night (sleep aid) with a start of 5/21/2021. A pharmacist's recommendation located in the resident's clinical record dated 6/28/2021 indicated for facility to ask the physician to renew or discontinue the Temazepam order and document the rationale on the resident's clinical record. No documentation in the clinical record was located the resident's attending physician was contacted or notified of the pharmacist's recommendation dated 6/28/21. During an interview on 7/30/2021 at 3:30 PM the infection preventionist (IP) acknowledged no discontinue or renew orders from the physician was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure one of 18 sampled residents (Resident 13's), Foley catheter (FC) [a tube that drains urine from the bladder], was documented in the medical record. This failure resulted in inaccurate documentation that can affect the delivery of safe care and treatments. Findings : During a review of the facilities policy & procedure (P&P) titled, Completion and Correction of Resident Records, dated 2/25/2016, the P&P indicated, To ensure that medical records are complete and accurate .in part . Entries will be complete, legible, descriptive, and accurate. During an observation on 07/28/21, 9:19 a.m., in Resident 13' room, Resident 13 was sleeping, FC bag was attached to the bed. During a review of Resident 13's Medical Doctor's Orders (MDO), dated 7/29/21, the MDO indicated, an order for FC. During a concurrent interview and record review, on 07/29/21, at 3:02 p.m., with Licensed Nurse (LN) 2, Resident 13's Licensed Nurse Record Weekly Summary (LNRWS), dated 7/27/21, was reviewed. The LNRWS indicated, no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to provide Pneumococcal (bacterial infection) immunizations for one resident (Resident 16). This facility failure had the potential to result in Resident 16 acquiring complications from Pneumococcal disease. Findings: Review of the facility policy and procedure titled, Influenza and Pneumonia Vaccinations, dated 10/1/2018, indicated in part . A physician's order for pneumococci shall be obtained .Nursing Care Duties (Licensed Nurse) Administer vaccination to resident. During an interview and concurrent record review on 07/30/21, at 10:22 AM, with the infection preventionist (IP), Resident 16's Pneumococcal Immunization informed consent dated 5/14/21 indicated Resident gave consent to get vaccine, IP confirmed to date Resident 16 has not received vaccine. IP stated, I admitted Resident 16 and haven't given vaccine I can't keep track. MD order was not obtained until today. During an interview with IP on 07/30/21, at 10:37 AM, IP confirmed the MD order should have been obtained and pneumococcal vaccine should have been given to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.