Maple Grove Nursing & Rehab Center

Based on observation, staff interview, and facility document review, the facility staff failed to ensure the safe and secure storage of medications and biologicals for 2 of 2 facility medication carts. The findings were: During a medication pass and pour observation on 10/16/24 at 8:03 AM, this surveyor observed Licensed Practical Nurse (LPN) # 1 leave the medication cart unattended with a vial of DuoNeb (ipratromium/albuterol liquid medication that is inhaled as a mist through a nebulizer machine). LPN # 1 left the cart on the A hall while they went to the medication room to look for another medication. During a medication pass and pour observation on 10/16/24 at 8:45 AM, this surveyor observed Registered Nurse (RN) # 1 leave a cup of Miramax (powdered laxative) mixed with 3 ounces of water on the medication cart unattended while they went to the medication room to look for another medication. When asked if leaving medication on the cart is acceptable, they stated, What should I have done? The policy entitled, Medication Storage with a revised date of 8/28/24 was reviewed and read…

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 staff interview, the facility staff failed to ensure proper disposal and/or containment of the facility's garbage/waste. The findings included: On 10/15/24 at 11:47 AM this surveyor employee # 1 made an observation of the facility's garbage disposal area located outside the facility but on the campus. There was one dumpster noted. All of the doors on the dumpster were shut. However, there was a large pile of debris beside the dumpster that included 5 computer screens and key boards, at least 5 wooden pallets, multiple wet, decorative [NAME] of hay, a case of outdated chicken noodle soup, two nightstands, multiple drinking straws, medication cups, drinking cups and surgical masks. Employee # 1 stated, They came and emptied it this morning, I don't know why they didn't pick this stuff up too. We couldn't put it in there because it was too full so we had to put it here. On 10/15/24 at 4:35 PM the survey team met with the Administrator, Director of Nursing, Assistant Director of Nursing 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, employee record review, and facility document review, the facility staff failed to follow their policy/procedures for screening of new employees for 1 of 25 new employees, new employee #15. The findings included: The facility staff failed to follow their policy for screening of new employees. The facility staff failed to provide evidence of screening for new employee #15. New employee #15 was identified as the Medical Director and had a hire date of [DATE]. The Administrator provided the surveyor with a copy of their policy titled, Abuse, Neglect and Exploitation. This policy read in part, .Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. 2. Screenings may be conducted by the facility itself, third-party agency 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 staff interview and clinical record review, the facility staff failed to ensure accurate Minimum Data Set (MDS) assessments for 3 of 20 residents, Residents #29, #57, and #4. The findings included: 1. For Resident #29, the facility staff failed to code the residents dialysis status on an annual MDS assessment. Resident #29's diagnoses included end stage renal disease and dependence on renal dialysis. Section C (cognitive patterns) of Resident #29's annual MDS assessment with an assessment reference date (ARD) of 08/08/24 included a brief interview for mental status (BIMS) score of 4 out of a possible 15 points. Per the MDS manual a score of 4=severe impairment in cognitive skills for daily decision making. Section O (special treatments/procedures/programs) was not coded to indicate this resident was receiving dialysis services. On 10/15/24, during initial tour of the facility the facility staff identified this resident as being out of the building for a dialysis treatment. Resident #29's comprehensive…

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, staff interview, family interview, and clinical record review, the facility staff failed to develop and/or implement a person-centered, comprehensive dietary care plan for 1 of 17 sampled residents, (Resident #6). The findings included: For Resident #6 the facility staff failed to develop and implement a comprehensive person-centered dietary care plan to address the resident's medical needs and/or preferences of being lactose intolerant. Resident #6's diagnosis list indicated diagnoses that included, but were not limited to, Arteriosclerotic Heart Disease, Hypertension, Old Myocardial Infarction, Atrial Fibrillation, Dementia, Age-Related Osteoporosis, Gastro-Esophageal Reflux Disease, and Diabetes Mellitus Type 2 (two). The most recent minimum data set (MDS) with an assessment reference date (ARD) of 9/20/24 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 for cognitive abilities, indicating the resident had severe impairment in cognitive abilities. Surveyor interviewed resident's daughter via phone conversation on…

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

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team for one (1) of 17 sampled residents, (Resident #4). The findings included: For Resident #4, the facility staff failed to review and revise the resident's comprehensive person-centered care plan to discontinue the focus for indwelling catheter that had been discontinued on 7/8/24. Resident #4's diagnosis list indicated diagnoses, which included, but not limited to, Alzheimer's Disease, Atrial Fibrillation, Diabetes Mellitus Type 2 (two), Neuromuscular Dysfunction of Bladder, Bipolar Disorder, and Chronic Viral Hepatitis C. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/18/24 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 for cognitive abilities, indicating the resident had severe impairment in cognitive abilities. Surveyor observed Resident #4 on 10/15/24 at 12:55 PM and no indwelling catheter was present at the time…

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, resident interview, staff interview, clinical record review and facility document review, the facility staff failed to obtain a physician's order for oxygen for one of 17 residents in the survey sample, resident # 23. The findings included: Resident # 23's diagnoses included but were not limited to chronic obstructive pulmonary disease (COPD), morbid obesity, heart failure and hypertension. The minimum data set (MDS) assessment with an assessment reference date of 8/29/24 assigned the resident a brief interview for mental status (BIMS) score of 15 out 15, indication intact cognition. On 10/15/24 This surveyor observed resident # 23 in their room. They were using oxygen via nasal cannula and the setting was 4 liters per minute (LPM). When asked if they knew how much oxygen they were getting they stated, Two (2) I believe. When asked if they needed the oxygen all the time or just sometimes they stated, I use it all the time. During a review of the clinical record an order that read, C-PAP on at QHS (every hour of sleep) and off in the AM with settings- IP-18,…

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, staff interview, facility document review, and during the course of a medication pass and pour observation, the facility staff failed to maintain processes to prevent the spread of infection and disease, and to ensure that Point of Care Devices are utilized safely, when used on multiple residents, by properly cleaning a glucose monitor between residents. The findings included: On 10/16/24 at 8:24 AM this surveyor observed Licensed Practical Nurse (LPN) # 1 during a medication pass, obtain a blood sugar level on a resident. They returned to the medication cart and used two alcohol prep pads to clean the glucometer they had used. When asked what the facility policy is for cleaning glucometers they stated, We use alcohol pads, that's what we've always done. We clean them before and after each patient. On 10/16/24 AT 9:06 AM this surveyor interviewed the Assistant Director of Nursing. When asked what the policy for cleaning glucometers was, they stated, We clean them with alcohol preps before and after we use them. Surveyor asked for the policy and 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 staff interview, clinical record review, facility document review and during a medication pass and pour observation, the facility staff failed to ensure a medication error rate of less than 5%. There were 2 errors in 32 opportunities for a medication error rate of 6.25 %. These errors affected Resident #38. For Resident #38 the facility staff failed to administer the correct doses of the medications Vitamin D3 (cholecalciferol) and Diltiazem. Diltiazem is a calcium channel blocker used to treat hypertension. The findings included: Resident #38's face sheet listed diagnoses which included but not limited to hypertension, atherosclerotic heart disease, chronic kidney disease, anxiety, depression, and asthma. Resident #38's most recent quarterly Minimum Data Set with an assessment reference date of 04/12/22 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. The Surveyor observed registered nurse (RN) #1 during a medication pass and pour on 05/16/22 at 8:00…

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 observations, staff interviews, and review of a facility document, it was determined the facility staff failed to ensure ensure that residents receive treatment and care for one (1) of 18 sampled residents (Resident #23) as evidenced by a failure to follow physician orders concerning the administration of digoxin. The findings included: Resident #23 was a resident in the facility at the time of this survey on 3/9/2020 through 3/12/2020. The resident had the admitting diagnoses of, but not limited to atrial fibrillation, high blood pressure, diabetes, end stage renal disease, dementia and depression. On the most recent MDS (Minimum Data Set) coded the resident as having a BIMS (Brief Interview for Mental Status) score of 10 out of a possible score of 15. Resident #23 was also coded as requiring extensive assistance with (2) or more staff members for dressing and personal hygiene and being totally dependent on (1) or more staff members for bathing. During the medication pass observation on 03/10/20 at 08:40 AM LPN (licensed practical nurse) #1 was preparing medications 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 interviews and document review, it was determined the facility staff failed to ensure pharmacist medication regimen reviews were acted on by a provider for two (2) of 18 sampled residents (Resident #38 and Resident #48) as evidence by the absence of provider response documentation. The findings include: 1. The facility staff failed to ensure a provider acted on Resident #38's medication regimen review, dated 1/22/2020. Resident #38's diagnoses included, but were not limited to: high blood pressure, kidney disease, coronary artery disease, anxiety, depression, and chronic respiratory failure. Resident #38's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 1/24/2020, had the residents Brief Interview for Mental Status (BIMS) scored as a 14 out of 15 and the Resident Mood Interview scored as 16 out of 27. Resident #38 was assessed as requiring extensive assistance of two (2) or more individuals with bed mobility, transfers, dressing, and toilet use. Resident #38's progress notes included a pharmacy note, dated 1/22/2020, that indicated 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 observations, staff interviews, and the review of a facility document, it was determined the facility staff failed to accurately label a medication for one (1) of 18 sampled residents as evidenced by the label not corresponding with the correct duration of the medication to be administrated to the resident (Resident #52). The findings include: Resident #52 was in the facility in the time of this survey, 3/9/2020 thorough 3/12/2020. On the most recent MDS (Minimum Data Set), the resident was coded as requiring extensive assistance of 2 staff members for dressing and personal hygiene and being totally dependent on 2 staff members for bathing. Resident #52 was also coded as having a BMS (Brief Interview for Mental Status) had problems with long and short term memory and was moderately impaired in decision making Resident #52's admitting diagnoses included, but not limited to atrial fibrillation, high blood pressure, diabetes, dementia and depression. During the medication observation on 3/10/22020 at 8:12 am with LPN (licensed practical nurse) #1, the surveyor observed LPN #1…

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 observations, staff interviews, and review of a facility document, it was determined the facility staff failed to maintain an infection prevention and control program for one (1) of 18 sampled residents as evidenced by bringing a bottle of blood glucose strips into the resident's room and not cleaning the bottle before storing them in the medication cart and by not changing a pair of dirty gloves before opening the resident's blinds (Resident #23) The findings included: Resident #23 resided in the facility while an unannounced Medicare/Medicaid survey was conducted from 3/9/2020 through 3/12/2020. The resident had the admitting diagnoses of, but not limited to atrial fibrillation, heart failure, arthritis, dementia and chronic obstructive pulmonary disease. On the most recent MDS (Minimum Data Set) coded the resident as having a BIMS (Brief Interview for Mental Status) score of 10 out of a possible score of 15. Resident #23 was also coded as requiring extensive assistance with two (2) or more staff members for dressing and personal hygiene and being totally dependent on one…

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.