Maple Grove Wellness & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide showers for three residents (Resident #1, #60, and #81) out of 18 sampled residents and two residents (Resident #5 and #34) outside the sample. The facility census was 86. 1. Review of Resident #1's medical record showed: - An admission date of 04/08/15; - Diagnoses of muscle weakness, need for assistance with personal care, and spastic hemiplegia of left non-dominant side (characterized by stiffness and muscle tightness on one side of the body, affecting motor function, coordination, and balance). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment to be completed by the facility), dated 07/10/25, showed: - No cognitive impairment; - Impairment on one side for both upper and lower extremities; - Substantial/maximal assistance from staff for upper and lower body dressing; - Substantial/maximal assistance from staff for personal hygiene; - Dependent on staff for showering. Review of the…

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 the resident's bilateral nephrostomy tube (a thin flexible tube inserted into both kidneys to drain urine directly into a drainage bag) drainage bags containing urine were lower than kidney level and exposed drainage bags were covered by privacy bags for one resident (Resident #12) out of one sampled resident. The facility census was 86. Review of the facility's policy, Catheter, Care Of, revised 06/20, showed:- Purpose: to prevent catheter-associated urinary tract infections while ensuring that residents are not given indwelling catheters unless medically necessary;- A resident, with or without a catheter, receives the appropriate care and services to prevent infections to the extent possible;- Daily catheter care: wash hands, don gloves prior to handling the catheter, drainage system or bag;- Explain the procedure to the resident and provide privacy;- Cleanse the area;- Remove gloves and wash hands;- Position the catheter…

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 communication forms that reflected ongoing coordination and collaboration between facility staff and the dialysis staff were sent with two residents (Resident #20 and #48) out of two sampled residents on all dialysis days. The facility census was 86.Review of the facility's Dialysis Care Policy, revised June 2020, showed: - The facility will be responsible for the overall care delivered to the resident, monitoring of the resident prior to and after the completion of each dialysis treatment and providing for all dialysis needs during the time period when dialysis is received; - The facility will maintain a contract with dialysis service provider; - The facility will arrange dialysis care for residents as ordered by the physician; - The facility will arrange transportation to and from dialysis, as well as meals, medication and a method of communication between the dialysis center and facility; - The nursing staff will communicate pertinent…

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 four out of the four sampled Certified Nurse Aides (CNAs) received an annual performance review. The facility census was 86.The facility did not provide a policy for CNA annual performance reviews.1. Review of CNA F's personnel file showed:- Hire date of 09/19/24;- No documentation of an annual performance review.2. Review of CNA G's personnel file showed:- Hire date of 07/16/24;- No documentation of an annual performance review.3. Review of CNA N's personnel file showed:- Hire date of 07/01/24;-No documentation of an annual performance review.4. Review of CNA O's personnel file showed:- Hire date of 07/01/24;- No documentation of an annual performance review.During an interview on 08/29/25 at 2:35 P.M., the Director of Nursing (DON) said CNA Performance Reviews are to be done by the DON, but they are probably not being done.During an interview on 08/29/25 at 7:30 P.M., the Administrator and DON said they would expect nurse aides to have a performance review completed every 12 months.

Based on interview and record review, the facility failed to ensure that medication usage was evaluated on an ongoing basis, by not providing documentation of monthly medication regimen reviews by the pharmacy for three residents (Resident #1, #9, and #11) out of 18 sampled residents and one resident (Resident #5) outside the sample. The facility census was 86. Review of the facility's policy titled Documentation and Communication of Consultant Pharmacist Recommendations, dated 08/2020, showed: - The consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist's observations and recommendations regarding residents' medication therapies are communicated to those with authority and/or responsibility to implement the recommendations and are responded to in an appropriate and timely fashion; - A record of the consultant pharmacist's observations and recommendations is made available in an easily retrievable form to nurses, prescribers, and the care planning team. This should include documentation of the date each medication regimen review is…

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 staff failed to conduct regular inspections of all bed frames, mattresses and side rails as part of a regular maintenance program for five residents (Residents #1,#2, #10, #72, and #81) out of 18 sampled residents and three residents (Resident #18, #34, and #64) outside the sample. The facility census was 86.Review of the facility's Bed Rail policy, last reviewed June 2020, showed: - Decisions to use or discontinue the use of bed rails will be made in the context of an individual assessment; - The facility will regularly review residents' condition and circumstances to reduce the use of bed rails as restraints while ensuring safety; - The assessment should include an evaluation of alternatives to the use of bed rails attempted and how the alternatives failed to meet resident needs; - If bed rails are used, assess the resident for risk of entrapment and ensure the bed's dimensions are appropriate for the resident's size and weight; - The…

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 failed to provide a safe and functional environment for the residents by allowing items to be stored on top of overbed light fixtures in seven resident rooms. Storing items on the overbed light creates a hazard of the items falling on the resident below, and does not utilize the light fixtures as intended. The deficient practice had the potential to affect all residents and staff in the facility. The facility census was 86. The facility did not provide a policy regarding storing objects on resident light fixtures. 1. Observation on 08/26/25 of resident rooms showed: - At 12:30 P.M., room [ROOM NUMBER] Bed B with a picture on the overbed light; - At 1:13 P.M., room [ROOM NUMBER] Bed A with two ball caps on the overbed light; - At 1:15 P.M., room [ROOM NUMBER] Bed C with a stuffed fish and an orange blanket folded up on the overbed light; - At 2:05 P.M., room [ROOM NUMBER] Bed B with several hats across the overbed light. 2. Observation on 08/27/2025 of resident…

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 the required trainings for three of three sampled Certified Nurse Aides (CNAs). This deficient practice had the potential to affect all residents. The facility census was 86.The facility did not provide a policy regarding the required annual nurse aide training requirements.1. Review of CNA F's in-service record showed:- A hire date of 11/25/24;- No documented hours of in-services from 11/25/24 through 08/15/25;- No documented training on dementia care/management, abuse prevention, neglect, areas of weakness that might need extra training, special needs of residents or training for cognitively impaired residents.2. Review of CNA G's in-service record showed:- A hire date of 07/16/24;- A total of 51 in-services dated from 09/20/24 through 08/15/25;- No documented training on dementia care/management, special needs of residents, or training for cognitively impaired residents.3. Review of CNA N's in-service record showed:- A hire date of 07/01/24;- A total of 46 in-services dated from 09/20/24 from 08/15/25;- 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow physician's orders for 19 of 43 residents who reside on the 100 hall (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18 and #19). The facility census was 79. The facility did not provide a policy on medication administration. 1. Review of Resident #1's medical record showed: - admitted on [DATE]; - Diagnosis of Type II Diabetes Mellitus (a chronic condition where the body either doesn't produce enough insulin or can't properly use the insulin it produces, leading to high blood sugar levels) and Hypothyroidism (when your thyroid gland doesn't make and release enough hormone into your bloodstream). Review of the resident's physician's order sheet (POS) dated June 2025 showed: - An order for Humalog (rapid-acting insulin used to manage blood sugar levels in people with type 1 and type 2 diabetes) Kwikpen 100 unit injection per sliding scale; - An order for Levothyroxine (used to treat hypthyroidism) 75…

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 staff failed to ensure proper antibiotic stewardship for one resident (Resident #1) of eight sampled residents when the facility failed to notify the resident's physician for a urinary tract infection (UTI) based on the results of the culture and sensitivity (C&S) (a laboratory test of the urine that shows what antibiotic will treat a specific organism) of the urinalysis (UA). The facility census was 78. 1. Record review of the facility revised policy dated June 2020, showed: - The Infectious Preventionist or other similarly qualified healthcare professionals, will educate nursing staff to obtain and communicate pertinent clinical information to physicians to promote appropriate diagnosis and prescribing antibiotics; 2. Record review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 01/25/2025 showed: - admission to facility on 12/02/2011; - Diagnoses of diabetes, chronic kidney disease Stage 2 (a progressive loss of kidney function,…

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 provide a minimum of two showers per week for five residents (Residents #1 #2, #4, #5, and #6) out of six sampled residents. This deficient practice could potentially affect all residents. The facility's census was 92. Review of the facility policy titled, Showering a Resident, undated, showed a shower/bath is given to the residents to provide cleanliness, comfort and to prevent body odors. Residents are offered a shower at a minimum of once weekly and given per resident request. Review of the facility policy titled, Bed Baths, undated, showed a bed bath is given to residents to promote cleanliness and comfort and to stimulate circulation. Residents are given bed baths as scheduled. Review of the facility's Resident Council Meeting Minutes, dated, 06/26/24, showed resident complaints of showers were still not getting done twice a week. 1. Review of Resident #1's medical record showed: - Diagnoses of supra ventricular tachycardia (SVT- an…

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 and interview, the facility failed to repair the convection oven, stove top burners, flat top grill, and oven. This had the potential to affect all residents. The facility failed to ensure outside food stored in residents' personal refrigerators was stored at least 40 degrees or below, failed to ensure expired foods were thrown away and refrigerators were cleaned regularly. This deficient practice affected three residents (Resident #64, #69, and #444) out of 19 sampled residents and one resident (Resident #43) outside the sample and had the potential to affect all residents with personal refrigerators. The facility census was 92. Review of the facility's policy titled, Foods Brought by Family/Visitors undated, showed food brought by family/visitors that is left with the resident to consume later will be labeled and dated with a use by date and stored in a manner that is clearly distinguishable from facility-prepared food. Perishable foods must be stored in a re-sealable container with a tight-fitting lid in a refrigerator below 40 degrees. Containers will be…

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 develop a Quality Assurance and Performance Improvement Plan (QAPI - a written plan containing the process that will guide the facility's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved.) The facility census was 92. Review of the facility's policy, Quality Assurance and Performance Improvement Program, revised February 2020, showed: - The QAPI committee oversees implementation of our QAPI plan, which is the written component describing the specifics of the QAPI program, how the facility will conduct its QAPI functions, and the activities of the QAPI committee; - The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include tracking and measuring performance, establishing goals and thresholds for performance measurement, identifying and prioritizing quality deficiencies, systematically analyzing underlying causes of systemic quality deficiencies, developing and implementing corrective action or…

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 the Quality Assurance Performance Improvement (QAPI) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. This had the potential to affect all residents in the facility. The facility census was 92. Review of the facility's policy, Quality Assurance and Performance Improvement Program, revised February 2020, showed: - This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents; - The administrator is responsible for assuring that this facility's QAPI program complies with federal, state, and local regulatory agency requirements; - The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include tracking and measuring performance, establishing goals and thresholds for performance measurement, identifying and prioritizing quality deficiencies, systematically…

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 maintain quarterly Quality Assurance and Improvement Program (QAPI) committee meetings with the required members. The facility census was 92. Review of the facility's Quality Assurance and Performance Improvement Program - Governance and Leadership policy, revised March 2020, showed: - The quality assurance and performance improvement program is overseen and implemented by the QAPI committee, which reports its finding, actions, and results to the administrator and governing body; - The administrator, whether a member of the QAPI committee or not, is ultimately responsible for the QAPI program; - The governing body is responsible for ensuring that the QAPI program is implemented and maintained to address identified priorities; is sustained through transitions of leadership and staffing; is based on data, resident and staff input, and other information that measures performance; and focuses on problems and opportunities that reflect processes, functions, and services provided to the residents; - The following individuals…

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 notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for transfer, and failed to notify a representative of the Office of the State Long-Term Care Ombudsman for 10 residents (Resident #2, #4, #11, #14 #52, #56, #64, #67, #85, and #444 ) out of 19 sampled residents. The facility's census was 92. Review of the facility's policy, Discharge Summary Form and Transfer to a Hospital with Bed Hold Form Documentation, undated, showed: - Upon obtaining a discharge order to transfer a resident to the hospital, the Transfer to Another Facility form is to be filled out explaining the reason why the resident is being transferred and explaining the bed hold policy; - After explaining to the resident why he/she is being transferred, the bed hold policy is explained and the resident is to sign the document; - If the transfer is a 911 transfer, the guardian/responsible party/next of kin is 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.

Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week. This deficiency had the potential to affect all residents. The facility census was 92. The facility did not provide a RN coverage policy. Review of the nursing schedules for February 1, 2024 through April 30, 2024, showed: - No RN scheduled for 02/17/24; - No RN scheduled for 03/02/24; 03/03/24; 03/16/24; 03/17/24; 03/30/24; 03/31/24; - No RN scheduled for 04/13/24; 04/14/24; 04/27/24; 04/28/24; - No RN scheduled for 11 days out of 90 days. During an interview on 05/07/24 at 5:16 p.m., the Administrator said she would expect the facility to have RN coverage for at least eight hours a day for seven days a week.

Based on interview and record review, the facility failed to notify residents of the availability and location of the most recent survey results in an accessible location to residents. This deficient practice had the potential to affect all residents and visitors. The facility's census was 92. The facility did not provide a policy. During a resident council meeting on 05/02/24 at 2:58 P.M., Resident #6, #26, #47, #57, #79 and #87 collectively said they were not aware of a binder that had survey results or the placement of it. During an interview on 05/01/24 at 3:30 P.M., the Administrator said they had been unable to find the survey results, among other things, since the administration change. During an interview on 05/07/24 at 5:09 P.M., the Administrator said there had been a new survey binder created and it was placed on the front table.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to consistently document a code status for one resident (Resident #56) out of 19 sampled residents and one resident (Resident #6) outside the sample. The facility's census was 92. Review of the facility's Advanced Directives policy, revised [DATE], showed: - Prior to or upon admission of a resident, the social services director (SSD) or designee will inquire about the existence of written advance directive; - The resident or representative will be provided written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if chosen to do so; - The resident or representative is given the option to accept or decline assistance; - Nursing staff will document, in the medical record, the offer to assist and the resident's decision to accept or decline assistance; - Information about whether or not the resident executed an advance directive will be displayed prominently in the medical record that is…

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 provide a safe, clean, comfortable, and homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 92. Review of the facility's general cleaning procedure check off list, undated, showed: report all dirty curtains or cubical blinds, burnt out light bulbs, or items that are missing from the room to the housekeeping supervisor so that any maintenance issues can be given to the maintenance director for repairs in the rooms. Observations of room [ROOM NUMBER] showed: - On 04/30/24 at 12:57 P.M., the resident's oxygen concentrator had debris on the filter and on left side of the concentrator. Twenty drywall patches on the walls of the room and on the corner by the closet and by the window that were not painted over; - On 05/03/24 at 2:00 P.M., the resident's oxygen concentrator had debris on the filter and on left side of the concentrator. Twenty dry wall patches on the…

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 discharge documentation that included appropriate communicated information to receiving facility such as basis for transfer, specific needs that couldn't be met, facility attempts to meet needs and special instructions or precautions for on-going care, including a copy of the resident's discharge summary, to ensure a safe and effective transition of care for one resident (Resident #92) out of three sampled residents. The facility's census was 92. Review of the facility's policy, Discharge Summary and Plan, revised October 2022, showed: - When a resident's discharge is anticipated, a discharge summary and post-discharge plan is developed to assist the resident with discharge; - The discharge summary includes a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of discharge in accordance with established regulations governing release of resident information and as permitted by the resident; - As part of the discharge summary, the nurse reconciles all…

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 inform the resident and/or legal representative in writing of their bed hold policy at the time of transfer to the hospital for ten residents (Residents #2, #4, #11, #14, #52, #56, #64, #67, #85, and #444) out of 19 sampled residents. The facility's census was 92. Review of the facility's policy, Discharge Summary Form and Transfer to a Hospital with Bed Hold Form Documentation, undated, showed: - Upon obtaining a discharge order to transfer a resident to the hospital, the Transfer to Another Facility form is to be filled out explaining the reason why the resident is being transferred and explaining the bed hold policy; - After explaining to the resident why he/she is being transferred, the bed hold policy is explained and the resident is to sign the document; - If the transfer is a 911 transfer, the guardian/responsible party/next of kin is to be notified and the reason for the transfer and the bed hold policy is explained; - Completing the discharge…

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 complete a significant change Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility) assessment for one resident (Resident #67) out of 19 sampled residents and one resident (Resident #6) outside the sample. The facility's census was 92. Review of the facility's policy titled, MDS Completion and Submission Timeframes, revised October 2023, showed timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument (RAI) Manual. Review of the RAI Manual, revised October 2023, showed: - The Assessment Reference Date (ARD) must be within 14 days from one of the following: 1) the effective date of the hospice election revocation (which can be the same or later than the date of the hospice election revocation statement, but not earlier than); 2) the expiration date of the certification of terminal illness; or 3) the date of the physician's or medical…

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 document an accurate Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) for four residents (Resident #2, #9, #64, and #69) out of 19 sampled residents and one resident (Resident #6) outside the sample. The facility census was 92. Review of the facility's policy titled, MDS Completion and Submission Timeframes, revised October 2023, showed timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument (RAI) Manual. 1. Review of Resident #2's medical record showed: - An admission date of 07/16/15; - Diagnoses of cerebral palsy (a disorder of movement, muscle tone, or posture), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and diabetes mellitus (a group of diseases that result in too much sugar in the blood); - An order for pioglitazone (a non-insulin diabetes medication), 15 milligrams (mg) daily, dated 08/04/23; - No order for insulin; - A quarterly MDS assessment,…

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 update and revise care plans with specific interventions to meet individual needs for two residents (Resident #67 and #444) out of 19 sampled residents. The facility census was 92. Review of the facility's policy, Care Plans, Comprehensive Person-Centered revised March 2022, showed: - The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; - The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission; - The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. - The comprehensive, person-centered care plan: includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest…

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 follow physician's orders for two residents (Resident #11 and #56) out of 19 sampled residents and failed to obtain a treatment order for one resident (Resident #11) out of 19 sampled residents. The facility's census was 92. Review of the facility's Medication and Treatment Order policy, revised July 2016, showed: - Medications and treatments will be consistent with principles of safe and effective order writing; - Did not address following physician orders for medication administration. Review of the website www.drugs.com showed: - Take levothyroxine tablets and capsules on an empty stomach, at least 30 to 60 minutes before breakfast with a full glass of water; - Take the medicine at the same time each day. 1. Review of Resident #11's medical record showed: - An admission date of 06/01/08; - Diagnoses of hypothyroidism (underactive thyroid that produces too few hormones, causing the metabolism to slow down), nutritional anemia (deficiency in vitamins and/or minerals) and shortness of breath; - An order for levothyroxine…

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 staff provided the necessary care and services in accordance with professional standards of practice for two residents (Resident #67 and #444) out of 19 sampled residents. Staff failed to follow policies, procedures, and physician orders regarding peripherally inserted central catheter (PICC) line care and administration of intravenous (IV) Antibiotics. The facility census was 92. Review of the facility's policy, Peripheral and Midline IV Catheter Flushing and Locking, dated March 2022, showed: - For short and long peripheral venous catheters (PIVCs - a thin, soft tube placed into a peripheral vein for venous access to administer intravenous therapy such as medication and fluids) and midline catheters (a thin, soft tube that is placed into a vein, usually in the arm) used for intermittent infusions, flush the catheter and aspirate for blood return prior to each infusion and at least every 24 hours to assess catheter function. Lock following each use; - Use a syringe barrel size of I0 milliliters (mL) or greater when…

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 screen four residents (Resident #4, #11, #69, and #444) out of five sampled residents for Tuberculosis (TB - a communicable disease that affects the lungs characterized by fever, cough and difficulty breathing.) The facility's census was 92. 1. Review of the facility's policy, Screening Residents for Tuberculosis, revised August 2019, showed: - This facility shall screen all residents for tuberculosis infection and disease; - The admitting nurse will screen referrals for admission and readmission for information regarding exposure to or symptoms of TB; - If a potential resident has been exposed to active TB or is at increased risk of TB infection, he or she will be screened for latent tuberculosis infection (LTBI) using tuberculin skin tests (TS) or interferon gamma release assay (IGRA); - Screening of new admissions or readmissions for tuberculosis infection and disease is in compliance with state regulations; - The facility will conduct an annual risk assessment to determine risk of exposure; - Residents…

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 and interview, the facility failed to provide a dining room large enough to accommodate the residents. This affected one resident (Resident #14) out of 19 sampled residents and three residents (Resident #26, #28, and #84) outside the sample and had the potential to affect all residents. The facility census was 92. The facility did not provide a dining room policy. 1. Observation on 04/30/24 at 12:29 P.M. of the main dining room showed: - 11 round tables with room for four chairs at each table; - Total of 44 seating places to dine; - One table with five residents. 2. Observation on 05/01/24 at 12:56 P.M. showed an unknown staff member squeezing between tables bumping two residents' chairs while they were eating. 3. Observation of the assisted dining room on 05/02/24 at 12:11 P.M. showed: - 21 seating places for residents and staff to assist with dining in the assisted dining room; - A total of 65 seating places in the two dining rooms. During an interview on 04/30/24 at 12:31 P.M., Resident #14 said he/she gets food and takes it back to his/her room because the…

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 failed to provide a safe and functional environment for the residents by allowing items to be stored on top of overbed light fixtures for residents in three rooms. Storing items on the overbed light creates a hazard of the items falling on the resident below, and does not utilize the light fixtures as intended. The deficient practice had the potential to affect all residents and staff in the facility. The facility census was 92. The facility did not provide a policy for overbed lighting safety. Review of the Receipt of Facility Rules and Regulations, included in the facility's admission packet, showed residents are not allowed to store personal items, including clothing, on the heater/air conditioner unit or the overhead light fixture. This is considered a safety hazard. 1. Observation of room [ROOM NUMBER], bed two, showed: - On 04/30/24 at 3:10 P.M., three stuffed animals on the light over the bed; - On 05/01/24 at 9:40 A.M., three stuffed animals on the light…

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 conduct at least twelve hours of nurse aide in-service education per year. This affected two out of two sampled Certified Nurse Assistants (CNA) D and E. The facility's census was 92. 1. Record review of CNA D's in-service record showed: - A hire date of 04/10/19; - A total of one hour of annual in-service training for April 2023 through April 2024; - Less than twelve hours of in-service education for April 2023 through April 2024. 2. Record review of CNA E's in-service record showed: - A hire date of 03/11/19; - A total of four hours of annual in-service training for April 2023 through April 2024; - Less than twelve hours of in-service education for April 2023 through April 2024. During an interview on 05/07/24 at 5:16 p.m., the Administrator said she would expect CNAs to have at least 12 hours of in-service education per year. The facility did not provide an in-service training policy.

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This has the potential to affect all residents. The facility census was 92. Record Review of the facility's Cleaning and Sanitizing Procedures policy, dated March 2021, showed: Purpose is to ensure that all staff are aware of the dietary department policy for proper cleaning and sanitizing procedures; In terms of cleaning and sanitizing, staff will implement the steps listed: - Scrape and remove excess soil from utensils; - Turn on automatic water-detergent faucet, fill up sink, and wash utensil clean; - Rinse utensils with clean water in rinse sink; - Sanitize by immersing utensils for 1 minute in solution; - Food Service Director will ensure proper procedures, and will direct random weekly audits to ensure compliance; - Failure to properly follow this procedure will result in disciplinary action. 1. Observations of the dry food storage room on 11/29/22 at 11:08 A.M. showed: - Water heater…

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 maintain infection control practices for three residents (Residents #3, #13, and #87) out of four sampled residents and two residents outside of the sample (Residents #43 and #80) during medication administration when facility staff did not wash or sanitize their hands during medication administration or utilize proper technique during catheter care. Additionally, staff failed to clean the glucometer (a small, portable machine that is used to measure how much glucose - a type of sugar - is in the blood) after use per policy or manufacturer's directions. The facility's census was 92. Record review of the facility's Handwashing policy, undated, showed: - To maintain infection control and prevent the spread of disease; - Handwashing to be done before and after resident care, during resident care when glove changes are made, or at any time hands become soiled. Record review of the facility's Perineal (the area between the anus and the scrotum) Care policy, undated, showed: - The purpose of this policy is 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.

Based on observation, interview, and record review, the facility failed to ensure a resident's dignity with a properly covered urinary catheter bag (a bag for collecting urine from a tube in the bladder) for one resident (Resident #27) out of 19 sampled residents. The facility census was 92. 1. Record review of Resident #27's facility admission Face Sheet dated 9/07/22 showed he/she was admitted with the following diagnoses: - Benign prostatic hyperplasia without lower urinary tract symptoms; - Urinary tract infection, site not specified. Observation of Resident #27 showed: -On 11/29/22 at 2:46 P.M., the resident laid in bed with eyes closed while his/her catheter bag laid in the floor beneath his/her bed uncovered with urine in the bag; -On 11/30/22 at 3:29 P.M., the resident laid in bed while his/her catheter bag laid in the floor beneath his/her bed uncovered with urine in the bag; -On 12/01/22 at 11:50 A.M., the resident laid in bed with eyes closed with his/her catheter bag in the floor uncovered with urine in the bag; -On 12/02/22 at 9:16 A.M., the resident took med pass while…

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 provide a safe, clean, and comfortable homelike environment. The facility census was 92. Record review of the facility's Resident Council minutes, dated 11/23/22, showed: - Residents want the privacy curtains checked and switched out if they are dirty. rooms [ROOM NUMBERS] would like theirs changed out. Observations on 11/29/22 at 11:20 A.M. and 1:43 P.M., on 11/30/22 at 4:04 P.M., and on 12/2/22 at 1:30 P.M. showed: - A yellow privacy curtain in room [ROOM NUMBER], Bed B had a reddish-brown colored, dried substance on it, approximately 1 inch (in) in diameter; - A yellow privacy curtain in room [ROOM NUMBER], Bed A had a light gray, dirty appearance along the bottom of the curtain. Observations on 11/29/22 at 12:40 P.M. and 1:38 P.M., on 12/1/22 at 10:26 A.M., and on 12/2/22 at 1:25 P.M. showed: - The exterior surface of the window in room [ROOM NUMBER] was partially covered with a large brown, dusty, cobweb-like substance. Observation…

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 follow their grievance policy by not making the information on how to file a grievance or complaint visible and/or available to all residents residing in the facility. The facility census was 92. Record review of the facility's Resident Grievance or Complaint Process Policy, dated 5/17/17, showed: - The resident has the right to voice grievances to the facility or other agency or entity that hears grievances and without fear of discrimination or reprisal; - Each resident, upon admission, is given an information document on the Grievance process. The name of the individual to receive the complaint/grievance as well as their phone number is on the document; - The Grievance Officer or Director of Social Services will oversee the initiation and resolution of all grievances; - When a resident, family member or responsible party voices a complaint or grievance verbally or in writing, the staff member receiving the complaint should notify the Grievance Officer and a grievance form is to be filled out; - Written…

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 implement a care plan with specific interventions to meet individual needs for two residents (Resident #13 and #48) out of 19 sampled residents. The facility census was 92. Record review of the facility's Residents Care Plan Updating policy, undated, showed: - To assure that all residents have an accurate and updated plan of care that reflect those individual needs and correlates with the submitted MDS; - Each resident's chart will be reviewed quarterly and/or with a change of condition, by a committee consisting of Care Plan Coordinator, Dietary, Wound Care Nurse, Therapy, Nursing, Activities and Social Services; - Charge nurse to inform MDS (Minimum Data Set - federally mandated process for clinical assessment)/Care Plan Coordinator with any updated or changed assessments on resident. Care plans to be updated as needed to reflect the new plan of care; - Care Plan Coordinator to address any needs or services generated by updating the care plan; - Resident's skin integrity, cognition, behavior, mood,…

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 provide consistent resident care for activities of daily living (ADL's) for four residents (Resident #15, #22, #41, and #63) out of 19 sampled residents. The facility census was 92. 1. Record review of Resident #15's quarterly Minimum Data Sheet (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 10/22/22, showed: - Required physical help in part of bathing with set up assistance. Record review of the facility shower sheets from September 1, 2022 through December 1, 2022 showed the resident received a shower on 9/9/22, (5 days later) on 9/14/22, (7 days later) on 9/21/22, (3 days later) on 9/24/22, (4 days later) on 9/28/22, (29 days later) on 10/27/22, (7 days later) on 11/3/22, (17 days later) on 11/20/22, and (7 days later) on 11/27/22. Record review of the facility's electronic records system showed the activity did not occur for the month of September. It showed a shower occurred on 10/8/22 and…

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 provide appropriate treatment and services to maintain or improve the highest level of function for one resident (Resident #55) out of 19 sampled residents. The facility census was 92. Record review of Resident #55's medical record showed: - An admission date of 6/14/19; - Diagnoses of anoxic brain damage (caused by a complete lack of oxygen to the brain), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and pain. - An order for Occupational Therapy to evaluate and treat one time for wheelchair positioning, dated 9/4/19; - An order for Physical Therapy, Occupational Therapy, and Speech Therapy to evaluate and treat, dated 6/19/19. Record review of a quarterly Interdisciplinary Resident Screening form completed by Physical Therapy, dated 1/8/19, showed: - Moderate assist with bed mobility; - Assist of one for feeding; - Maximum assist with transfers; - Some limits with active or…

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 document accurate immunization status, provide information and education to each resident or the resident's representative of the influenza vaccine (a vaccine used to protect against influenza) and pneumococcal vaccines (a vaccine used to protect against pneumonia bacteria) for two residents (Residents #69 and #81) out of five sampled residents. The facility's census was 92. Record review of the facility's Pneumococcal Immunizations policy, undated, showed: - Resident immunization status will be assessed upon admission/readmission; - Pneumococcal immunization will be provided to the resident and/or responsible party and education will be performed explaining immunization recommendations and possible vaccine side effects or adverse reactions. Documentation of such will be written in the medical record; - The Facility's Immunization Consent Form will be completed and signed by the resident and/or responsible party indicating the desire to receive or…

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.