Alliance Health at Maples

Inspectors wroteBased on document review and interview, the facility failed to solicit and consider input received from direct care staff, residents, resident representatives, and family members when conducting the facility assessment.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure all drugs and biologicals used in the facility were stored in a safe and secure manner as required for two Residents (#9 and #121), from a sample of 27 residents. Specifically, the facility failed to ensure:1. For Resident #9, that prescribed topical wound treatment supplies were not left unsecured and unattended at the Resident's bedside; and2. For Resident #121, that antifungal powder was not left unsecured and unattended at a resident's bedside.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to ensure:1. For Resident #9, who has a stage 4 pressure ulcer (Full thickness tissue loss with exposed bone, tendon, or muscle), that staff implemented Enhanced Barrier Precautions (EBP-an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities); and2. Surveillance documents in use by the facility, were complete and accurate each month.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure care was provided to residents in accordance with professional standards of practice for two Residents (#9 and #69), from a total sample of 27 residents. Specifically, the facility failed to ensure: 1. For Resident #9, an air mattress was set according to physician's orders; and2. For Resident #69, oxygen was administered according to physician's orders.

Inspectors wroteBased on document review and interview, the facility failed to provide the most updated COVID-19 vaccination to one Resident (#11), out of a total sample of 27 resident, after the Resident consented to receiving the vaccination.

Inspectors wroteBased on record review and interviews, the facility failed to ensure staff maintained accurate medical records for one Resident (#9), out of a total sample of 27 residents. Specifically, the facility failed to ensure nursing staff accurately documented the anatomic location of a stage 4 pressure wound to the Resident's right buttock.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff provided adequate supervision to one Resident (#77), out of a total sample of 26 residents, who was identified as a high fall risk and received anticoagulant medication (medication that prevents blood from clotting). Specifically, the facility failed to ensure staff provided adequate supervision and/or implemented adequate interventions in an effort to prevent five falls in one month, one of which resulted in the Resident being transferred to the hospital emergency department for evaluation, and he/she was diagnosed with a subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain).

Inspectors wroteBased on record review and interview, the facility failed to ensure the Resident Representative was notified of a change in treatment for one Resident (#77), out of a total sample of 26 residents. Specifically, the facility failed to notify the Resident Representative when the Nurse Practitioner ordered the discontinuation of anticoagulant (medication that prevents blood from clotting) therapy following a fall resulting in a subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain).

Inspectors wroteBased on record review and staff interview, for one Resident (#88), of three closed records reviewed, the facility failed to document the recapitulation of the Resident's stay that included his/her course of illness/treatment.

Inspectors wroteBased on records reviewed and interviews, the facility failed to ensure for two Residents (#13 and #15), out of five residents selected for unnecessary medication review, that each Resident's drug regimen was free from unnecessary psychotropic medications. Specifically, the facility failed to ensure: 1. For Resident #13, an Abnormal Involuntary Movement Scale (AIMS) assessment (a clinical outcome checklist completed by a healthcare provider to assess the presence and severity of adverse outcomes, such as abnormal movements of the face, limbs, and body) was completed timely in accordance with standards of practice; and 2. For Resident #15, as needed (prn) antidepressant medication was limited to 14 days, or extended beyond 14 days with a documented clinical rationale for its continued use and identified a clinical indication for use.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to establish and maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases and infections in the facility. Specifically, the facility failed to: 1. Ensure that healthcare personnel performed hand hygiene following the self-collection of a nasal swab sample to rule out COVID-19; 2. Ensure that healthcare personnel donned (put on) the appropriate personal protective equipment (PPE) prior to entering a precaution room as indicated by posted signs outside of the resident's room; and 3. Ensure staff performing aerosol generating procedures for COVID-19 residents were properly fit-tested for an N-95 mask, prior to performing the procedure.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for two Residents (#112 and #233), out of a total sample of 27 residents. Specifically, the facility failed to follow their policy for investigating and reporting alleged allegations of abuse documented in the facility's Grievance Book for: 1. Resident #112's alleged allegation of sexual assault; and 2. Resident #233's alleged allegation of physical abuse.

Inspectors wroteBased on observation, policy review, record review, and interviews, the facility failed to develop a comprehensive person-centered care plan for two Residents (#59 and #74), out of a total sample size of 27 residents. Specifically, the facility failed: 1. For Resident #59, to develop a comprehensive care plan for the care and treatment of left and right heel pressure ulcers within 21 days of admission to the facility, per facility policy; and 2. For Resident #74, to develop a comprehensive care plan for the use of a psychotropic medications.

Inspectors wroteBased on record review and interviews, the facility failed to obtain a hearing assistive device in a timely manner for one Resident (#29), out of a sample of 27 residents.

Inspectors wroteBased on policy review, record review, observations, and staff interviews, the facility failed to obtain physician's orders for oxygen use prior to administration for one Resident (#384), in a total sample of 27 residents.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to follow their policy and consistently complete the facility's section of the Dialysis communication sheet prior to dialysis treatment for one Resident (#59), out of a sample of 27 residents.

Inspectors wroteBased on record review and interview, the facility failed to monitor for signs/symptoms of adverse consequences (i.e., side effects) of an anticoagulant agent (blood thinner) prescribed for one Resident (#90), out of a total sample of 27 residents.

Inspectors wroteBased on document review, interview, and record review, the facility failed to ensure one Resident (#2), out of a total sample of 27 residents, was free from a significant medication error when an antibiotic was stopped without a physician's order during the facility's transitioning to an electronic medical record system.

Inspectors wroteBased on record review and interview, the facility failed to ensure the medical record was complete and accurate for three Residents (#74, #90, and #2), out of a total sample of 27 residents. Specifically, the facility failed: 1. For Resident #74, to ensure an order to admit the Resident to hospice services was integrated into the current physician orders when transitioning to an electronic medical record; 2. For Resident #90, to ensure the monitoring for signs and symptoms of bleeding with the use of anticoagulant medication was being documented; and 3. For Resident #2, the facility failed to ensure an order for an antibiotic had been included in a data transfer.

Inspectors wroteBased on Minimum Data Set (MDS) assessment review and staff interview, the facility failed to ensure staff completed the Comprehensive MDS Assessment within the required time frame for six Residents (#109, #23, #83, #6, #50, and #71), out of a total sample of 22 resident assessments reviewed.

Inspectors wroteBased on Minimum Data Set (MDS) assessment review and staff interview, the facility failed to complete Quarterly MDS assessments timely for 15 Residents (#42, #25, #18, #119, #105, #15, #10, #53, #77, #26, #55, #20, #82, #117, and #97), out of a total sample of 22 resident assessments reviewed.