Maple Crest Health Center

No Licensure Reference Number Based on observation, record review and interview, the facility failed to ensure that the posted nurse staffing information contained the required information related to the total number of hours worked per discipline. This had the potential to affect all residents that resided in the facility. The facility census was 143. The findings are: Record review of a facility policy entitled Facility Posted Nurse Staffing dated 7/24 revealed the following information.Policy Explanation and Compliance Guidelines:1. The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information:a. Facility nameb. The current datec. Facility's current resident censusd. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered Nurses ii. Licensed Practical Nurses/Licensed Vocational Nurses iii. Certified Nurse Aides Observation on 08/27/25 at 10:00 AM, 08/28/25 at 10:40 AM, and 09/02/25 at 9:40 AM revealed the posted nursing…

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 LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, record review and interview; the facility staff 1) failed to utilize hand-washing and gloving techniques to prevent potential food contamination during food preparation and meal service and 2) store foods in a manner to prevent potential food borne illness. This practice had the potential to affect all residents in the facility who ate meals from the kitchen. The facility also failed to monitor refrigerator temperatures daily on resident personal refrigerators. This had the potential to affect all residents that used the unit refrigerator on [NAME] and [NAME] Units. The facility census was 143.Findings are: A. Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: -2-301.14 Food employees shall wash hands and exposed portions of their arms immediately before engaging in food…

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.

Licensure Reference Number 175 NAC 12-006.04(F)(i)Licensure Reference Number 175 NAC 12-006.09Licensure Reference Number 175 NAC 12-006.09(H)(iii) The facility failed to notify the physician and resident representative when ordered daily weights were not obtained or documented for 1 ( Resident 58) of 1 sampled resident and failed to notify physician of changes in skin condition for 1 (Resident 15) of 1 sampled resident. The facility census was 143.A. A record review of Resident 58's Weights & Vitals on August 28, 2025 revealed 86 missed daily weights from April 1 through August 26, 2025. No refusals or provider notifications were documented. A record review of facility's Change in Condition policy with, revised date April 2023 revealed staff are required to immediately notify the physician/resident representative of significant changes in condition or failure to implement treatment orders. No evidence of such notification was found. A record review of Resident 58's monthly weight logs for April through August 2025 revealed multiple gaps: April 2025: 17 missed days of daily weights…

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 LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(H)Based on record review and interview, the facility failed to implement interventions to prevent the potential for verbal abuse for 2 (Resident 8 & 59) of 2 residents sampled. The facility staff identified a census of 143.The findings are:Record review of a facility policy entitled Abuse Prohibition Program dated revised 8/8/2024 revealed: -Policy Statement: residents have the right to be free from abuse, neglect, misappropriation of resident property, and involuntary seclusion by anyone, including by not limited to - facility staff, other residents, volunteers, staff of other agencies serving the resident, family members, legal guardians, and friends. Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, and systems to assist in preventing resident abuse. -2. Our abuse prevention/intervention program includes, but is not necessarily limited to the following: -b) The protection 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(H)Based on interview and record review, the facility staff failed to report an allegation of verbal abuse within the required timeframes for 2 (Resident 8 & 59) of 2 sampled residents. The facility staff identified a census of 143.The findings are:Record review of a facility policy entitled Abuse Reporting dated revised 8/8/2024 revealed: -3. All personnel, residents, family members, visitors, etc., are encouraged to report incident of resident abuse or suspected incidents of abuse. Such report may be made without fear of retaliation from the facility or its staff. -4. Employees, facility consultants and/or Attending Physicians must immediately report any suspected abuse or incidents of abuse to the Administrator/Director of Nursing/Social Services director. -5. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator/Director of Nursing/Social Services director. The following…

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.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(D)Based on record review and interview, the facility failed to complete the Quarterly Minimum Data Set (MDS, a federally mandated assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) within the required time frames for 2 (Resident 14 & 119) of 35 sampled residents. The facility staff identified a census of 143.The findings are:Record review of the Resident Assessment Instrument (RAI) Manual Version 1.18.11 effective 10/01/23 revealed a quarterly MDS must be completed and signed no later than 14 days from the assessment reference date.A. Record review of Resident 14's MDS with a reference date of 8/6/2025 revealed the MDS was not signed as completed until 8/26/2025 which is 20 days after the reference date.B. Record review of Resident 119's MDS with a reference date of 6/23/2025 revealed the MDS was not signed as completed until 7/24/2025 which is 31 days after the reference date.An interview on 9/3/2025 at 11:53 AM with MDS Coordinator (MDSC)-A confirmed the MDS'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.

Licensure Reference Number 175 NAC 12-006.09(H)(i)(3)Based on record review, observation and interview; the facility failed to ensure nail care was provided for Resident 15. The sample size was 1 and the facility census was 143. Findings are:Review of the facility policy titled Shower and Bathing with a revised date of 5/17/22 included the following:-The facility would provide routine personal hygiene for the residents and assess the condition of the resident's skin on a weekly basis. -The resident fingernails would be cleaned and trimmed on resident bath day. Review of Resident 15's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 6/19/25 revealed the resident's cognitive skills for daily decision making was severely impaired. The resident was dependent on staff for toileting hygiene, personal hygiene, bathing, upper and lower extremity dressing, rolling left to right, going from sitting to lying position, chair/bed to chair transfer, tub transfer and wheelchair mobility and was always incontinent of bowel and bladder. 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 Licensure Reference Number 175 NAC 12-006.09(H)(iii)(3)Licensure Reference Number 175 NAC 12-006.09 The facility failed to ensure physician orders were followed by not obtaining and documenting daily weights for Resident 58, and failed to perform weekly skin evaluations for Resident 15, and weekly wound evaluations for Resident 5, and failed to implement interventions to prevent skin breakdown for Resident 62. The facility census was 143. The findings are:A. A record review of Resident 58's Weights & Vitals on August 28, 2025 revealed 86 missed daily weights from April 1 through August 26, 2025. No refusals or provider notifications were documented. A record review of facility's Change in Condition policy with, revised date April 2023 revealed staff are required to immediately notify the physician/resident representative of significant changes in condition or failure to implement treatment orders. No evidence of such notification was found. A record review of Resident 58's monthly weight logs for April through…

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 Licensure Reference Number 175 NAC 12-006.09(H)(iii)(1) Based on record review and interview the facility failed to conduct weekly skin evaluations to prevent the potential for pressure ulcer development for 2 (Resident 5 and 12) of 2 residents sampled. The facility census was 143. The findings are: A.Record review of the facility policy titled Skin assessment dated [DATE] revealed it the facility policy to perform a full body skin assessment as part of our systemic approach to pressure injury prevention and management. A full body, or head to toe, skin assessment will be conducted by a licensed nurse upon admission/readmission, for 3 days and weekly thereafter.Record review of Resident 5's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 06-14-2025 revealed the facility staff assessed the following about the resident:-Brief Interview of Mental Status (BIMS) was scored at a 12. According to the MDS Manual a score of 8-12 indicates moderate cognitive impairment.-Had 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC12-006.12E1 Based on observation, interviews, and record review, the facility failed to secure one medication for 1 (Resident 55) of 4 sampled residents and failed to secure a medication cart on the first floor. The facility identified a total of 102 residents resided on the first floor and identified 8 residents who were self-mobile and had poor safety awareness. The facility census was 150. Findings are: A. Record review of clinical census in resident's electronic medical record revealed Resident 55 admitted to the facility on [DATE] with diagnoses including: Chronic Obstructive Pulmonary Disease (a common lung disease causing restricted airflow and breathing problems), Congestive Heart Failure (a serious condition when the heart doesn't pump blood as well as it should), Chronic Kidney Disease (means a gradual loss of kidney function over time), Morbid (severe) Obesity due to excess calories (a complex chronic disease in which a person has a body mass index (BMI) of 40 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.

Licensure Reference Number 175 NAC 12-006.09B Based on observations, record review, and interviews, the facility failed to maintain the nutritive value of pureed food. This had the potential to affect 18 residents. The facility identified a census of 150. Findings are: Observation on 7/9/24 at 9:10 AM revealed [NAME] B scooped with a slotted spoon an indeterminate amount of cooked green beans into the blender. [NAME] B measured 2 teaspoons of salt and put it in the blender with the green bean. [NAME] B added 2 scoops of liquid butter to the blender and added boiling water of indeterminate amount. After this mixture was blended, [NAME] B added 4 ounces of thickener. Observation on 7/9/24 at 9:30 AM [NAME] B placed an indeterminate amount of cooked ground beef into the blender. [NAME] B added 2 scoops of country gravy and 2 cups of boiling water into the blender. After this mixture was blended, [NAME] B added 4 ounces of thickener. A interview was conducted on 7/10/24 at 8:40 AM with [NAME] B. During the interview [NAME] B reported having already pureed the meat for lunch. [NAME] B…

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 LICENSURE REFERENCE NUMBER 175 NAC 12-006.07(C) Based on record review and interview; the facility staff failed to identify and offer the Pneumococcal immunization to 4 (Resident 122, 138, 130, and 80) of 5 sampled residents. The facility staff identified a census of 150. Findings are: A. Record review of Facility Policy dated 8/2016 Pneumococcal Vaccine: Policy Statement: All residents will be offered Pneumococcal vaccines to aid in preventing pneumonia/Pneumococcal infections. Policy Interpretation and Implementation 1. Prior to or upon admission, residents will be assessed for eligibility to receive the Pneumococcal vaccine series, and when indicated, will be offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 2. Assessment of Pneumococcal vaccination status will be conducted within 5 days of the resident admission if not conducted prior to admission. 3. Before receiving a Pneumococcal vaccine, the resident 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 LICENSURE REFERENCE NUMBER 175 NAC 12-006.04 (F)(i)(5) Based on record review and interview, the facility staff failed to notify the physician of a missed dialysis appointment for 1 of 1 residents (Resident 54). The facility identified a census of 150. Findings are: Record review of Resident 54's Census Sheet revealed an admission date of 3/12/2019 to the facility and had the diagnoses of Renal Dialysis Record review of Resident 54's Minimum Data Set (MDS, a federally mandated assessment tool used for care-planning) dated 5/8/2024 revealed Resident 54 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) with a score of 15. According to the MDS [NAME] a score of 13 to 15 indicates a person is cognitively intact. Resident 54 required set up/clean up assist with eating, substantial/maximum assist with bed mobility and toileting, and was dependent for transfers and had the diagnosis of renal insufficiency, renal failure, End Stage Renal Disease (ESRD). Record…

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.

Licensure Reference Number 175 NAC 12.006.02(H) Based on record review and interview, the facility failed to complete a thorough written investigation and report an allegation of staff to resident abuse within the required timeframe to the Department of Health and Human Services [DHHS] for 1 (Residents 143) of 3 facility self-report investigations reviewed. The facility census was 150. Findings are: Record review of 2 facility policies entitled Abuse Investigations and Abuse Reporting dated August 2006 revealed the following information: Abuse Investigations: 1. When the incident or suspected incident of resident abuse, neglect, or injury of unknown source is reported, the administrator will appoint a staff member to investigate the incident. 2. The person conducting the investigation will, as a minimum: a. An interview with the person reporting the incident. b. Interviews with any witnesses to the incident. c. An interview with the resident. d. An interview with the attending physician when deemed appropriate and a review of the residents' medical record. e. Am interview with staff…

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 Licensure Reference Number NAC 12-006.09 (B) Based on record review and interview, the facility failed to accurately identify Special Treatments in Section O-Special Treatments, Procedures, and Programs on the Minimum Data Set (MDS, a federally mandated assessment tool used for care-planning) for 2 (Residents 54 and 122) of 30 reviewed. The facility staff identified a census of 150. Findings are: A. Record review of Resident 54 Census Sheet revealed an admission date of 3/12/2019 to the facility with the diagnoses of Dependence on Renal Dialysis. Record review of Resident 54's MDS dated [DATE] revealed the Resident 54 had renal insufficiency, renal failure, End Stage Renal Disease (ESRD) marked on the MDS. Section O, Question J 1 Dialysis revealed the MDS was not coded for Dialysis treatment. A interview on 07/10/24 at 2:38 PM was conducted with the MDS Coordinator. During the interview the MDS Coordinator confirmed the MDS dated [DATE] should have had Section O-Question J 1 marked for Dialysis While a 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a new PASRR (Pre-admission Screening and Resident Review, a screening to determine the presence of a mental illness or intellectual disability) referral had been completed after a diagnosis of a mental disorder was identified for 1 (Resident 57) out of 3 reviewed for PASRR screens. The facility census was 150. Findings are: Record review of a facility policy entitled Admissions and PASRR update policy dated 5/25/23 revealed the following information: 4. PASRR process: - a. Screening: The discharging hospital or nursing home staff or designated PASRR coordinator shall conduct an initial screening of all individuals seeking admission to determine if there is a reasonable suspicion of serious mental illness, intellectual or developmental disabilities, or both. Screening may involve a review of medical records, assessments, and interviews with the individual or their authorized representative. Re-screens or status updates of residents may 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to accurately complete a Level I PASARR screen (PASARR, a federally mandated screening process to ensure Nursing Home residents will mental illness and/or developmental disabilities receive the care and services they need in the most appropriate setting) for 1 (Resident 23) of 2 sampled residents. The facility census was 150. Findings are: Record Review of PASARR screen dated 05/04/2018 revealed Resident 23 was assessed as having no diagnosis or suspicion of Serious Mental Illness (SMI) or Intellectual Disability or Related Condition (ID/RC). Record Review of Facility's Diagnosis Report for Resident 23 revealed the following admission diagnoses which would have triggered a Level II screen: -Vascular Dementia, mild, with mood disturbance -Moderate intellectual disabilities -Major Depressive Disorder, recurrent, moderate -Generalized Anxiety Disorder -Unspecified Psychosis not due to a substance or known physiological condition Record Review 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.

Licensure Reference Number 175 NAC 12.006.09(H)(i)(3) Based on observation, interview, and record review the facility failed to provide position changes and incontinence care for 1 (Resident 33) of 4 residents. The facility census was 150. Findings are: Record Review of Resident 33's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 05-27-2024 revealed Resident 33 had the diagnosis of Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), Lewy body Dementia (a disease associated with abnormal deposits of a protein called alpha-synuclein in the brain. These deposits, called Lewy bodies, affect chemicals in the brain whose changes, in turn, can lead to problems with thinking, movement, behavior, and mood.), Schizophrenia (Schizophrenia is a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), and Depression. The MDS also indicated Resident 33 was not able complete a Brief…

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 Licensure Reference Number 175 NAC 12-006.09(I)(i)(1) Based on observations, record review and interviews, the facility failed to implement assessed interventions to prevent skin injuries for Resident 105 and falls for Resident 63. A total of 4 residents were reviewed for accident prevention. The facility census was 150. Findings are: A. Record review of Resident 105's annual Minimum Data Set (MDS) (a federally mandated comprehensive assessment tool used for care planning) dated 4/7/24 identified an admission date of 7/7/24. The MDS Identified that Resident 105 had a Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) score of 5 which indicated severe cognitive impairment. The MDS identified that Resident 105 exhibited inattention and disorganized thinking, physical and verbal behavioral symptoms, and rejection of care 1-3 days per week, required wheelchair use for ambulation, required substantial to maximum assistance with transfers from the bed to 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 Licensure Reference Number 175 NAC 12-006.14 Based on observation, record review and interview, the facility failed to ensure 1 (Resident 55) of 1 sampled residents received follow up dental services. The facility census was 150. Findings are: An interview with Resident 55 was conducted on 07/08/2024 at 9:54 AM. During the interview, Resident 55 reported that they had no teeth, was seen and fitted for dentures in April (2024) and that they were still waiting for their dentures. A record review on 07/09/2024 of a Doctor Referral Form for Resident 55, dated 05/20/2024 revealed Resident 55 was seen by the dentist with the following notation tried in teeth in wax. Patient approved. Next Visit-Deliver Dentures. A review of Resident 55's medical record revealed there was not any evidence that the facility had any contact with the dentist from 05/21/2024 through 07/08/2024. An interview with facility's Social Worker (SW) on 07/09/2024 at 2:22 PM confirmed that the facility was unaware that Resident 55 hadn't received…

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 LICENSURE REFERENCE NUMBER 178 NAC 1-005.06(D) Based on observation, record review and interview, the facility staff failed to perform hand hygiene and gloving to prevent cross contamination in 2 residents (Resident 122 and Resident 33) of a sample size of 30. The facility identified a census of 150. Findings are: A. Record review of Resident 122's Census Sheet revealed the resident was readmitted to the facility on [DATE]. Record review of Resident 122's Minimum Data Set (MDS, a federally mandated assessment tool used for care-planning) dated 4/21/2024 revealed a Brief Interview of Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) with a score of 6. A score of 6 indicated the resident was severely cognitively impaired. Resident required substantial/maximal assist with eating and was dependent for toileting, bed mobility, and transfers. Record review of Resident 122's Care plan revealed an intervention dated 3/5/2024 for catheter cares every shift. Care plan entry dated 5/3/2024…

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 Licensure Reference Number 175 NAC 12.006.17D Licensure Reference Number 175 NAC 12.006.17B Licensure Reference Number 175 NAC 12.006.17E Based on observation, interview, and record review, the facility failed to ensure staff completed handwashing in a manner to prevent cross contamination (transfer of bacteria from one surface to another), ensure expired items were removed from the facility's stock, ensure the floors in the walk-in refrigerator and walk-in freezer were clean, and ensure kitchen equipment was clean and in good working order. This had the potential to affect 144 residents that consumed (ate) food from the kitchen. The total facility census was 146. Findings are: A. A record review of the undated Maple Crest Hand Washing Policy revealed the staff should have washed their hands to prevent the spread of infection and disease by washing hands thoroughly with soap for 20 seconds. An observation on 07/12/2023 at 9:02 AM revealed the facility's [NAME] (CO)-C completed the process of pureeing (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.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on record review and interview; the facility staff failed to report and thoroughly investigate an allegation of verbal abuse and submitted the investigation to the require state agency within 5 working days for 1(Resident 68) 1 residents. The facility staff identified a census of 147. Findings are: A. Record review of the facility Abuse Reporting policy dated 8-2006 revealed the following information: -Policy Statement: -It is the responsibility of our employees, facility consultants, attending Physican's, family members, visitors, etc, to promptly report any incident or suspect incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management, which will then be immediately reported to the appropriate state agencies and other entities or individuals. -Policy Interpretation and Implementation: -2c. Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents, or their…

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 Licensure Reference Number 175 NAC 12.006.09D2c Licensure Reference Number 175 NAC 12.006.09D Based on observation, interview, and record review, the facility failed to ensure a Prevalon Boot (a heel protector designed with an open, floated-heel design) was applied while at rest to prevent the potential for skin breakdown for 1 (Resident 406) of 2 sampled residents and the facility failed to monitor bowel movements and implement a bowel management program to prevent the potential for bowel complications for 1 (Resident 148) of 1 sampled resident reviewed for bowel management. The total facility census was 146. Findings are: A. A record review of the undated Maple Crest Skin Care (General) Policy revealed preventative skin care would be used whenever possible for residents at risk for skin breakdown. A record review of Resident 406's Clinical Census dated 07/11/2023 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 406's Medical Diagnoses dated 07/11/2023 revealed 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 Licensure Reference Number 175 NAC 12.006.09D7a Based on observation, interview, and record review, the facility failed to ensure that resident's footrests were applied to resident wheelchairs to prevent potential accidents while being transported (pushed or pulled) for 3 (Residents 24, 7 and 85) of 3 sampled residents. The total facility census was 146. Findings are: A record review of the Assistive Devices and Equipment Policy dated July 2017 revealed that equipment that assist with resident mobility, safety, and independence included wheelchairs. Staff can assist residents if wheelchair pedals are not present only if resident can independently lift their legs and maintain positions, if they cannot then foot pedals need to be added to the resident's wheelchair before transfer process occurs. To decrease the risk of avoidable accidents associated with a wheelchair, the facility would assess the resident for lower extremity (legs and feet) strength, range of motion, balance, and cognitive (thinking, reasoning,…

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.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.14 Based on observation, record review and interview; the facility staff failed to follow up on dental care for 1 (Resident 112) of 1 sampled resident. The facility staff identified a census of 147. Findings are: Record review of Resident 112's Progress Note dated 12-07-2022 revealed Nurse Practitioner (NP) M notified Social Services (SS) M Resident 112 needed to see a dentist. Review of Resident 112's medical record that included PN's, practitioner orders, referral section and assessment sections of the medical record revealed no indication follow up with a dentist had been completed. Observation on 7-10-2023 at 8:23 AM revealed Resident 112 was seated in a wheelchair in Resident 112's room. Further observation revealed Resident 112 had broken and blackish looking teeth. On 7-10-2023 at 8:23 AM during the observation, Resident 112 reported needing and wanted to see a dentist. Resident 112 reported not being aware if staff were attempting to assist in Resident 112 being able to see a dentist. On 7-11-2023 at 11:25 AM an interview 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.17B Based on observation, interview, and record review, the facility failed to ensure 2 (Residents 406 and 123) of 3 sampled resident's nebulizer (a machine used to deliver liquid medicine to the lungs) administration set (neb kit) and 1 (Resident 35) of 1 sampled resident's Continuous Positive Airway Pressure (CPAP)(a machine used to deliver pressure to the resident's airway to keep it open) mask was cleaned and stored in a manner to prevent potential cross contamination. The total facility census was 146. Findings are: A. A record review of the Medication Administration - Nebulizer Policy dated 05/13/2020 revealed after the treatment was complete the staff should have disassembled and cleaned the neb kit in warm soapy water after each treatment and stored the neb kit in a clean plastic bag. A record review of Resident 406's Clinical Census dated 07/11/2023 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 406's Medical Diagnoses…

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.