Maple Grove Health and Rehabilitation Center

Inspectors wroteBased on record review, observations, and interviews with the resident's Responsible Party, staff, Nurse Practitioner (NP), Medical Director, law enforcement, and the hospital physician, the facility failed to protect Resident #1's right to be free from injury of an unknown origin. Resident # 1 sustained facial swelling, hematoma and contusion extending from the right eye to the corner of his right lip. The source of the injury to Resident #1 was not observed by anyone, the source of injury could not be explained by the resident, and the injury was suspicious. On 10/09/25, Resident #1's was observed by Nurse Aide (NA) #2 to have swelling to the residents' right side of face. The resident was transferred to the hospital via Emergency Medical Services (EMS) who noted the resident had been assaulted by a facility staff member. [...]

Inspectors wroteBased on record review, and Responsible Party, dental provider Chief Operating Officer, Medical Director, staff and hospital physician interviews, the facility failed to provide the necessary assistance to obtain dental services for 1 of 3 residents reviewed for routine and emergency dental services (Resident #1).

Inspectors wroteBased on observation, record review and interviews with the resident and staff, the facility failed to provide a cognitively dependent resident with access to a hearing amplifier to accommodate a hearing deficit. This deficient practice occurred for 1 of 1 resident reviewed for accommodation of needs (Resident #96). The reasonable person concept was applied for Resident #96 due to his inability to hear what was happening around him. A reasonable person would feel social isolation, loneliness, and frustration.

Inspectors wroteBased on medical record review and staff interviews the facility failed to complete a significant change in status assessment for 1 of 1 resident reviewed for significant change (Resident #70).

Inspectors wroteBased on observations, record review, and interviews with resident and staff, the facility failed to provide nail care to a resident who needed extensive assistance from staff for Activities of Daily Living (ADL). This deficient practice affected 1 of 7 residents (Resident # 90) reviewed for ADLs.

Inspectors wroteBased on observations, resident and staff interviews and record review, the facility's Quality Assurance and Performance Improvement committee (QAPI) failed to maintain implemented procedures and monitor interventions the committee put into place following the annual recertification and complaint surveys dated 1/18/22 and current survey 3/06/24 in the area of accurately coding Minimum Date Set (MDS). The facility also failed to maintain implemented procedures and monitor interventions the committee put in place following the annual recertification and complaint surveys conducted on 1/18/22, 1/27/23 and the current survey 03/06/24, in the area of Activity of Daily Living (ADL) care provided for dependent residents. The continued failure during three federal surveys of record showed a pattern of the facility's inability to sustain an effective QAPI program.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area hearing, speech and vision for 1 of 1 resident reviewed for communication. (Resident #96).

Inspectors wroteBased on record review and staff and resident interviews, the facility failed to implement their policy for immediately notifying the Administrator of an allegation of abuse for 1 of 4 residents reviewed for abuse (Resident #4).

Inspectors wroteBased on record reviews and interviews with the consultant pharmacist, Nurse Practitioner, Medical Director, and a representative of the facility's contracted pharmacy, the facility failed to ensure there was an appropriate indication for prescribing an oral antibiotic shown to be ineffective against systemic infections for a resident with a surgical wound infection. This occurred for 1 of 4 residents (Resident #2) reviewed for the provision of care according to professional standards.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure dishware was stored and stacked clean and dry; The facility also failed to ensure the food items not provided by the facility were dated and labeled with the residents' names, dates and room numbers when stored in the snack/nourishment refrigerators; and food items served to but refused by residents were not stored in 1 of 3 residents' nourishment rooms. These practices had the potential to affect food served to residents.

Inspectors wroteBased on an observation and staff interviews, the facility failed to ensure the area surrounding 1 of 1 trash compactor remained free from standing water and refuse. These unsanitary practices had the potential to affect the environment of the residents.

Inspectors wroteBased on record review, resident and staff interviews, and review of the Resident Council Minutes, the facility failed to record and respond to concerns voiced by residents during Resident Council meetings for 8 of 12 months (April, May, July, August, September, October, November and December 2022).

Inspectors wroteBased on observation, record reviews, psychiatric nurse practitioner and staff interviews, the facility failed to administer duloxetine hydrochloride (an antidepressant medication) for eleven days as ordered by the psychiatric nurse practitioner for 1 of 5 sampled residents (Resident# 27) reviewed for unnecessary drugs.

Inspectors wroteBased on record review, resident representative interviews and staff interviews, the facility failed to explain to resident representatives that the binding arbitration agreement was not a condition of admission for 3 of 3 residents who entered into an Arbitration Agreement with the facility. (Resident #89, Resident #492, and Resident #493).

Inspectors wroteBased on observations, resident and staff interviews and record review, the facility's quality assurance (QA) process failed to implement, monitor, and revise as needed the action plan developed for the recertification and complaint surveys dated 2/4/20 and 1/18/22 and for complaint survey on 8/18/21 in order to achieve and sustain compliance. This was for recited deficiencies on a recertification survey on 1/27/23. The deficiencies were in the area of notice requirements before transfer/ discharge, Activity of Daily Living (ADL) care provided for dependent residents and residents free of significant medication errors. The continued failure during four federal surveys of record showed a pattern of the facility's inability to sustain an effective quality assurance program.

Inspectors wroteBased on staff interviews and record review, the facility failed to offer a pneumococcal (pneumonia) vaccine for 1 of 5 residents (Resident #69) reviewed for immunizations.

Inspectors wroteBased on record review, observation resident and staff interviews the facility failed to treat Resident #392, 1 of 1 resident reviewed for catheter care, with dignity. The facility failed to have Resident #239's catheter bag covered for privacy and dignity.

Inspectors wroteBased on observations, record review, and resident and staff interview ' s the facility failed to provide showers, nail care, and mouth care to residents who needed extensive and/or were dependent on staff for Activities of Daily Living (ADL). This was for 2 of 2 residents (Resident #79 and #80) reviewed for ADL ' s.

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to ensure the alternating pressure reducing air mattress was set according to the resident's weight for 1 of 2 residents reviewed for pressure ulcers (Resident #80).

Inspectors wroteBased on record review, review of the Nurse Aide Registry forms and staff interviews the facility failed to verify with the North Carolina (NC) Nurse Aide Registry a Nursing Assistant's (NA#12) certification for 1 of 3 employees reviewed (NA #12).

Inspectors wroteBased on record review and interviews with staff the facility failed to maintain a resident's record of refusal or if contraindicated for the vaccine for COVID-19 for 2 of 5 residents reviewed for COVID-19 vaccination status (Resident #44 and #242).

Inspectors wroteBased on record review and staff interviews, the facility failed to provide the resident and/or Responsible Party (RP) written notification of the reason for a hospital transfer for 3 of 3 residents reviewed for hospitalization (Residents #342, #442 and #80).

Inspectors wroteBased on staff interviews and record review, the facility failed to provide notice of the bed hold policy prior to transfer for 3 of 3 resident reviewed for hospitalizations (Residents #342, #442, #80).