Avenir at Maple Grove

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two residents (Resident #1, and #2) of five sampled residents, received incontinence care in a timely manner to prevent odors and maintain hygiene. Staff failed to check or change residents who were dependent on staff for assistance with incontinent care for over four hours. The facility census was 52. Review of the facility policy Activities of Daily Living, dated 1/1/26, showed a resident who was unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food items at a safe and appetizing temperature. Five residents (Resident #4, #3, #2, #1 and #5), of five sampled residents, reported staff served foods in the dining room and resident rooms that should be hot at service, cold. The issue had been reported repeatedly through the Resident Council with no resolution. The facility census was 58. Review of the facility policy, Food Safety Requirements, last reviewed/revised 09/25/23, showed the following: -It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety; -Holding: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Dietary Director had the appropriate competencies and skills set to carry out the function of the food and nutrition services. The facility census was 49. Review of the facility's undated job description for Director of Food Service/Dietary Manager Department, showed the following: -The Food Service Manager position is responsible for planning, organizing, developing, and directing the operations of the Dietary Department in accordance with federal, state, and local regulations and consistent with facility guidelines; -Functions with a moderate degree of independence and is evaluated on overall department performance based on resident satisfaction, employee performance, department safety, and department sanitation; -Directs and supervises production, preparation and service of resident meals; [...]

Inspectors wroteBased on observation, interview, and record review, staff failed to store, prepare, and serve food in accordance with professional standards for food service safety. Staff did not practice proper hand hygiene or hair restraint usage. Staff did not ensure food items were labeled or dated and did not ensure dented cans of food were removed from use. Staff did not ensure the dishwashing machine water temperature gauge was functioning and the appropriate chemical sanitizer was being applied to dishes. Staff did not maintain surfaces and equipment to be free from a buildup of debris or ensure items were stored dry and in a sanitary manner. The facility census was 49. 1. Review of the facility's undated policy, Hand Washing Procedure, showed the following: -Turn on faucets and adjust water temperature for comfort; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all staff members were provided with written documentation of education regarding the benefits, risks and potential side effects associated with the COVID-19 vaccine and/or refusal of the vaccine. Further review showed the facility failed to maintain documentation related to staff COVID-19 vaccination status, whether received or declined. The facility census was 49. Review of the Centers for Medicare and Medicaid Services (CMS) memo, QS0-25-14-NH, dated 03/10/25, showed the following: -The LTC facility must develop and implement policies and procedures to ensure all the following: -When COVID-19 vaccine is available to the facility, each staff member is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the staff member has already been immunized; [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the facility walls, ceilings, sink counter' and dining room/TV room chairs in good repair. The facility also failed to ensure the parking lot and driveway in front of the facility were free of damage and large potholes. The facility census was 49. Review of the facility's policy, Resident Rights, revised 05/04/22, showed the residents had a right to a safe, clean, comfortable, and homelike environment. 1. Observation on 04/29/25 at 8:12 A.M., in occupied resident room [ROOM NUMBER], showed a laminated countertop surrounded the sink. An approximate 6 foot section of the counter was damaged where the particle board showed through the laminated surface. The surface was very rough and had uneven edges directly in front of the sink. Observation on 04/29/25 at 8:13 A.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to update and revise the comprehensive care plan for three residents (Resident #9, #32 and #42) in a review of 19 sampled residents. The facility failed to update Resident #9's care plan to address continued risk for skin breakdown due to recent decline and decreased mobility, failed to update Resident #32's care plan to accurately reflect his/her care needs and failed to update Resident #42's care plan with intervention for wound care and enhanced barrier precautions (EBP). The facility census was 49. Review of the facility policy, Care Planning - Interdisciplinary Team, reviewed 01/2017, showed the following: -Policy: Every resident will be assessed using the Minimum Data Set (MDS) according to the guidelines set forth in the Resident Assessment Instrument (RAI) manual; -Purpose: 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff provided three residents (Resident #6, #32 and #33 ), in a review of 19 sampled residents, that were unable to complete their own Activities of Daily Living (ADL's), the necessary care and services to maintain good personal hygiene and prevent body odor. The facility census was 49. A request was made for, but the facility did not provide, a policy for ADL care, including oral care. Review of the facility's policy, Urinary Continence and Incontinence - Assessment and Management, reviewed 01/2017, showed the following: -If the resident does not respond and does not try to toilet, or for those with severe cognitive impairment, staff will use a check and change strategy; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure sufficient staff were on duty per the facility assessment, to meet the residents' needs. The facility census was 49. Review of the facility policy, Nursing Services and Sufficient Staff, dated 08/25/23, showed the following: -It is the policy of the facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident; -The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment; -The facility will supply services by sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff served meals to meet the nutritional needs of the residents when staff did not prepare and serve food according to the facility's diet spreadsheet menu for two residents (Residents #17 and #7), in a review of 19 sampled residents, and did not serve the appropriate portion sizes to five residents (Residents #17, #4, #5, #9, #25 and #29). The facility census was 49. 1. Review of Resident #17's Physician Orders, dated April 2025, showed the following: -Diagnoses included Alzheimer's disease, dementia, and dysphagia (difficulty swallowing); -An order for regular diet, mechanical soft texture, and double portions. Review of the facility's Diet Type Report, dated 04/25/25, showed the resident was to receive a mechanical soft diet and double portions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff utilized Enhanced Barrier Precautions (EBP) as required by facility policy when providing care and treatment to one resident (Resident #42), who had a wound, and also failed to ensure required signage was posted to indicate the use of EBP as required during high-contact personal care for two residents (Resident #42 and #33), in a review of three residents on EBP precautions. The facility failed to ensure staff performed proper hand hygiene when providing incontinence care to two residents (Resident #1 and #17), in a review of 19 sampled residents. The facility failed to implement their water management program to identify and reduce the risk of Legionella bacteria (cause of Legionnaire's disease - a severe form of pneumonia) growth and spread. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an infection prevention and control program (IPCP) that included a functional antibiotic stewardship program. In addition, the facility failed to ensure one additional resident (Resident #2), in a review of 19 sampled residents, had appropriate clinical indications for the use of an antibiotic The facility census was 49. Review of a Centers for Disease Control (CDC) undated document titled, The Core Elements of Antibiotic Stewardship for Nursing Homes showed the following: -Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority; -Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #8), in a review of 19 sampled residents, and one additional resident (Resident #28), the right to choose schedules (including waking times) and make choices about aspects of his/her life in the facility that were significant to the resident. The facility census was 49. Review of the facility policy, titled Resident Rights, revised 05/04/2022 showed the following: -The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to: -a. The resident has the right to choose activities, schedules (including sleeping and waking times), assessments, and plan of care and other applicable provisions of this part; -b. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment instrument, completed by staff, according to the Resident Assessment Instrument (RAI) manual for two residents (Resident #17 and Resident #48), in a review of 19 sampled residents. The facility census was 49. Review of the RAI Manual, dated October 2023, showed the following: -Medicare and Medicaid participating long-term care facilities are required to conduct comprehensive, accurate, standardized and reproducible assessments of each resident's functional capacity and health status; -The RAI process has multiple regulatory requirements. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided care and treatment in accordance with professional standards of practice when staff failed to follow physician orders in providing continuous oxygen to one resident (Resident #49) to maintain the resident's oxygen needs, in a review of 19 sampled residents. The facility census was 49. 1. Review of Resident #1's Care Plan, revised 01/15/25, showed the following: -He/She had oxygen therapy related to chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe); -Monitor for signs/symptoms of respiratory distress and report to physician as needed; -He/She has COPD/asthma; -Give oxygen therapy as ordered by the physician; -Monitor for difficulty breathing on exertion. Remind the resident not to push beyond endurance. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently accommodate one resident's (Resident #31's) food preferences and failed to serve an appropriate food substitute/alternate. The facility census was 49. Review of the facility policy, Food Preparation Guidelines, dated 2023, showed the following: -Strategies to ensure residents satisfaction include honoring resident preferences, as possible, regarding food and drinks; -Staff shall accommodate resident allergies, intolerances, and preferences, providing appropriate alternatives when needed; -Alternatives shall be appealing and of similar nutritive value to the food that is being substituted; -Alternatives shall be consistent with the usual and/or ordinary food items provided by the facility; [...]

Inspectors wroteRefer to Event ID UWJ112. Based on observation, interview, and record review, the facility failed to provide food items at a safe and appetizing temperature. The facility census was 48. Review of the facility policy for Food Safety Requirements, dated 9/25/23, showed: -Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety; -When preparing food, staff shall take precautions in critical control points in the food preparation process to prevent, reduce or eliminate potential hazards: -Foods shall be prepared as directed until recommended temperatures of the specific foods are reached. Staff shall refer to the current Food and Drug Administration (FDA) food code and facility policy for food temperatures as needed; [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure residents and/or their responsible parties (RPs) were invited to participate in the care planning process for 2 (Resident #22 and Resident #29) of 2 residents sampled for care planning requirements. Staff interviews revealed the facility had not involved residents or their RPs in the care planning process since March of 2020. This affected all residents in the facility.

Inspectors wroteBased on personnel record review, interviews, and facility document review, it was determined the facility failed to ensure 6 of 6 nurse aides (NAs) selected for review completed training to receive their certification within four months of their hire dates.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food items at a safe and appetizing temperature. The facility census was 48. Review of the facility policy for Food Safety Requirements, dated 9/25/23, showed: -Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety; -When preparing food, staff shall take precautions in critical control points in the food preparation process to prevent, reduce or eliminate potential hazards: -Foods shall be prepared as directed until recommended temperatures of the specific foods are reached. Staff shall refer to the current Food and Drug Administration (FDA) food code and facility policy for food temperatures as needed; -Staff shall monitor food temperatures while holding for delivery to ensure proper got and cold holding temperatures are maintained. [...]

Inspectors wroteBased on interviews, record review, and facility document and policy review, the facility failed to protect the resident's right to be free from physical abuse by another resident for 1 (Resident #4) of 3 residents reviewed for abuse prevention. Specially, the facility failed to prevent resident-to-resident abuse when they did not implement interventions immediately after the first indications of aggression.

Inspectors wroteBased on interviews and record review, the facility failed to notify the ombudsman in writing when a resident was transferred or discharged from the facility for 1 (Resident #254) of 3 residents reviewed for transfer and discharge. Specifically, the ombudsman was not notified regarding an emergency transfer to an acute care facility which was considered a facility-initiated transfer.

Inspectors wroteBased on interviews and document review, the facility failed to ensure that, in January 2023, there was a Director of Nursing (DON) on staff at the facility and failed to ensure a registered nurse (RN) was working eight consecutive hours a day, seven days a week.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to maintain a clean environment in the laundry area. This affected 1 of 1 laundry room in the facility and was observed on 2 of 4 days of the survey.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the range hood baffles and the ovens were clean and free of debris, failed to store scoops outside the food containers; failed to ensure serving trays and plate covers were not put away wet; and failed to ensure kitchen staff had all their hair covered with hairnets. The facility census was 42. Observation on 12/17/19 between 10:48 A.M. and 12:27 P.M. in the kitchen showed the following: -The range hood baffle filters were covered with a thick layer of grease and debris; -The bottoms of both ovens had a thick layer of debris; -A scoop was stored in the sugar bin. The handle of the scoop touched the sugar; -The tray covers were stacked wet on the counter, and the serving trays used during the noon meal service were wet; [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain within an appropriate timeframe Nurse Aide (NA) registry/background screenings for two new employees, in a review of five newly hired employees prior to employment to determine if any had a Federal indicator with the nurse aide registry that would prohibit employment at the facility. The facility census was 51. 1. During interview on 12/20/19 at 1:00 P.M. the administrator said the facility did not have a policy regarding NA registry or background screenings. The facility should follow the state regulation requirements. Review of the facility's policy Abuse, Prevention, and Prohibition and Policies and Procedures, revised 11/2018, showed the following: -The facility will not knowingly employ individuals who have been found guilty of abusing, neglecting or mistreating residents or misappropriating their properties; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff provided two of 14 sampled residents (Resident #31 and #16) and two additional residents (Resident #15, and #40) that were unable to do their own Activities of Daily Living (ADL's), the necessary care and services to maintain good personal hygiene and prevent body odor. The facility census was 51. 1. During interview on 12/20/19 at 1:00 P.M. the administrator said the facility did not have a policy regarding providing ADL cares. Staff should follow the Certified Nurse Assistant (CNA) manual and procedure learned in CNA training. Review of the facility's undated policy, Incontinence Care, showed the following: -Female: Cleanse lower abdomen, wiping from side to side, fold cloth over and cleanse remaining lower abdomen as above; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide sufficient nursing staff on the behavioral unit, to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by the resident assessments and individual plans of care for four of 14 sampled residents (Resident #25, Resident #31, Resident #4 and Resident #14), and for one additional resident (Resident #18) out of eight residents who resided on the facility's special care unit (SCU). The facility census was 51. 1. During interview on 12/20/19 at 1:00 P.M. the administrator said the facility did not have a policy regarding staffing on the SCU. 2. Review of Resident #18's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 10/23/19 showed the following: -Cognitively intact; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food that was palatable and at a safe and appetizing temperature. The facility census was 42. Review of the facility's policy for meal service temperatures, dated January 2019, showed temperatures of hot food shall be supported to promote service temperatures of hot food to about 120 degrees. Record review on 12/17/19 of the noon meal menu showed beef ravioli, marinara sauce, mixed vegetables, garlic bread stick, and pudding. Observation on 12/17/19 between 12:06 P.M. and 12:55 P.M. of the noon meal service showed staff prepared and served all residents the lunch meal. Observation on 12/17/19 at 12:55 P.M., of the test tray received after the last resident was served, showed the following food tempertures: -The ravioli was 98 degrees F; -The pureed ravioli was 112 degrees Farenheit (F); [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure staff washed their hands after each direct resident contact and when indicated by professional standard of practice during personal care for five residents (Resident #30, #16, #37, #13 and #48) in a sample of 14 residents and one additional resident (Resident #15) and failed to maintain and implement a comprehensive infection control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease) and failed to provide documented assessments for such an outbreak. The facility census was 51. 1. Review of the facility policy Infection Prevention and Control Manual, dated 2019 showed the following: Appropriate hand hygiene is essential in preventing transmission of infectious agents. Definitions: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for two residents (Residents #42 and #46), in a review of 13 sampled residents. Staff failed to obtain ordered medications including Xarelto (a blood thinning medication) and Acyclovir (treatment for herpes virus, shingles) for Resident #42, and failed to obtain ordered medications including Primidone (a seizure preventing medication) and Seroquel 25mg (an antipsychotic used for depression) for Resident #46. The facility census was 51. 1. During interview on 12/20/19 at 1:00 P.M. the administrator said the facility did not have a policy regarding following physician's orders. Review of the facility policy Medication Ordering and Receiving from the Pharmacy, dated June 1, 2018, showed the following: -Emergency pharmacy service is available on a 24-hour basis; [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct and develop a detailed facility-wide assessment to determine what resources were necessary to care for the residents competently during both day-to-day operations and during emergencies. The facility census was 51. 1. During interview on 12/20/19 at 1:00 P.M. the administrator said the facility did not have a policy regarding the facility assessment. Review of the facility assessment dated [DATE] showed a standardized assessment tool with suggestions for completion. The assessment did not contain the following: -Any ethnic, cultural, or religious factors with potential to affect the care provided by the facility; -Other pertinent facts or descriptions of the resident population that must be taken into account when determining staffing and resource needs; -Policies and procedures for provision of care; [...]