Maple Crest Health Center

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(iii)(1) and 12-006.09(H)(iii)(2). Based on observation, interview and record review the facility failed to implement and monitor interventions to prevent the development of pressure ulcers and to promote wound healing for 3 (Resident 1,2 and 3) of 4 residents sampled. The facility census was 150.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(F)(i)(5). Based on interview and record review the facility failed to notify the resident representative of a change of condition for 1(Resident 1) of 2 residents sampled. The facility census was 151.

Inspectors wroteLicensure Reference Number 175 NAC 1-005.04Based on record review and interview, the facility failed to resolve grievances and provide grievance resolution response for 1 (Resident 10) of 2 sampled residents. The facility staff identified a census of 151.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(H)Based on record review and interview, the facility failed to report an allegation of physical abuse to law enforcement within the required timeframe for 1 (Resident 6) of 3 sampled residents. Facility staff identified a census of 151.

Inspectors wroteBased on record review and interview, the facility failed to update the comprehensive care plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) to reflect the current resuscitation status for 1 (Resident 10) of 15 sampled residents. The facility staff identified a census of 151.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(iii)(3). Based on observation, interview and record review the facility failed to implement physician's orders to prevent altered skin integrity for 1 (Resident 5) of 3 residents sampled. The facility census was 151.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(iii)(1) & 12-006.09(H)(iii)(2). Based on observation, interview and record review the facility failed to develop, implement and reevaluate interventions for the prevention of pressure ulcer development and to promote wound healing for 2 (Resident 1 and 7) of 3 residents sampled. The facility census was 151.

Inspectors wroteLicensure Reference Number 175 NAC12-006.09 Based on observation, interview and record review the facility failed to coordinate the provision of medication administration with dialysis services and failed to adhere to physician ordered fluid restriction for 1 (Resident 5) of 1 residents sampled. The facility census was 151.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04. Based on interview and record review the facility failed to ensure timely response to call lights as evidenced by call light response times, greater than 30 minutes for 3 (Residents 4, 5 and 7) of 15 sampled residents. The facility census was 151.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10(D). Based on interview and record review the facility failed to ensure residents were free of significant medication errors for 1 (Resident 5) of 1 residents sampled. The facility census was 151.

Inspectors wroteBased on record review, observation, and interview, the facility staff failed to change gloves between residents during the provision of blood glucose monitoring, perform hand hygiene after doffing (removing) gloves, and handle glucose strips in a manner to prevent the potential for cross contamination for 2 (Residents 14 and 15) of 6 sampled residents; and the facility failed to use enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes. [...]

Inspectors wroteNo 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.

Inspectors wroteLICENSURE 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.

Inspectors wroteLicensure 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. [...]

Inspectors wroteLICENSURE 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.

Inspectors wroteLICENSURE 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.

Inspectors wroteLICENSURE 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLICENSURE 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.

Inspectors wroteLICENSURE 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLICENSURE 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.

Inspectors wroteLicensure 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.

Inspectors wroteLICENSURE 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLICENSURE 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.

Inspectors wroteLicensure 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.