Maple Healthcare Center

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the safe storage and labeling of emergency potable (safe to drink or suitable for human consumption) water reserve for 204 out of 204 bottled waters, 34 six-pack bottled water cases (of which 12 six-packs with Niagara brand and 22 six-packs with [NAME] brand). By failing to:Ensure all emergency potable water was not stored past the facility applied label indicating a use by date (peak freshness and container integrity, not that the water itself has spoiled. Water does not expire, but plastic bottles can degrade over time and leach chemicals which affect the taste and safety) of 11/28/2025, as per facility policy and procedure (P&P) titled Emergency and Disaster Procedures dated 11/25/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect private health information for two of two sampled residents (Resident 30 and Resident 31), by failing to ensure confidential medical information was not easily visible and accessible. This failure had the potential to result in a violation of Resident 30 and 31's right to personal privacy and confidentiality of their medical records.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) to meet the needs of two of 14 sampled residents (Resident 8 and Resident 10) by failing to:1. Develop a care plan for Resident 8's post-traumatic stress disorder (PTSD-a mental health condition triggered by experiencing or witnessing a terrifying event) diagnosis and Zyprexa (antipsychotic [medication that help calm the brain] medication) use.2. Develop a care plan for Resident 10's delusional (holding a strong, false belief that is completely out of touch with reality) thoughts of somatic (related to the body) symptoms behavior. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that was free from accidental hazards for one of five sampled days (7/10/2026) by failing to ensure the facility's front door was locked. This failure had the potential to result in residents wandering out of the facility, elopement (when a resident leaves/escapes from a facility without a physician's order and without the staff knowing) and vulnerability to external intruders entering the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to update and post daily the actual hours or projected hours worked by licensed and unlicensed staff providing direct care to the residents per shift on one of five sampled days (7/6/2026), as per the facility's policy and procedures (P&P) titled Posting Direct Care Daily Staffing Numbers, reviewed on 11/25/2025. This failure had the potential to prevent residents and visitors from knowing the accurate nurse staffing hours and had the potential to cause inadequate staffing and had the potential for the residents' needs to go unmet.

Inspectors wroteBased on interview and record review the facility failed to clarify physician orders for Eliquis (a prescription blood thinner) as recommended by the facility's consultant pharmacist (a healthcare professional who provides specialized expertise to healthcare facilities, typically focusing on ensuring the safe and effective use of medications) during the monthly Medication Regimen Review (MRR, when a consultant pharmacist reviews and analyzes a resident's medication list, ensuring that the medications are appropriate, effective, and safe) for one of six sampled residents (Resident 2). This failure had the potential for Resident 2 to experience adverse effects (undesired and harmful effects that occur because of a medication, treatment, or procedure) from Eliquis such as bruising, balance issues, and hemorrhage (uncontrolled bleeding).

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain infection control measures necessary to prevent the possible spread of infections for one of two sampled medication carts (medication cart 1-med cart 1). By failing to ensure the incinerator container (medication disposal container) was kept clean, closed and/or changed as needed. This failure had the potential to result in the spread of disease and infection to residents, visitors, and staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was protected from misappropriation of personal property by failing to safeguard Resident 1's debit card after identifying Resident 1 lacked the capacity to safely manage finances. This deficient practice resulted in Resident 1's debit card going missing while residing in the facility, unauthorized financial transactions, and psychosocial harm, as evidenced by Resident 1 reporting feeling upset, wanting to cry, and no longer feeling safe in the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its' policy and procedures (P&P) titled Abuse Investigation and Reporting dated 11/25/2025 by failing to report the misappropriation of property (Debit Card) for one of three sampled residents' (Resident 1). This deficient practice resulted in multiple unauthorized transactions on 6/1/2026 on Resident 1's debit cards. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its bed-hold policy for a resident who was transferred to general acute care hospital (GACH) by not reserving the resident's bed during hospitalization in accordance with the facility's policy and procedures (P&P) titled, Bed-Holds and Returns, reviewed 1/25/20 and regulatory requirements for one of three sampled residents, Resident 1. This deficient practice had the potential to result in the residents' delay returning to the facility and disruption in continuity of care.

Inspectors wroteBased on interview and record review the facility failed to report to the State Survey Agency (SSA) within two hours of a resident-to-resident altercation for two of four sampled residents (Resident 1 and Resident 2). On 2/6/26 at 10:47 a.m., Resident 1 and Resident 2 had a verbal and physical altercation. The facility reported the incident to the SSA on 2/6/26 at 4:05 p.m. This deficient practice had the potential to under report alleged cases of resident abuse to the SSA and may delay the investigation to ensure Resident 1 and Resident 2 were safe.1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the resident had the capacity (a person's ability to make their own decisions about their healthcare) to understand and make decisions to be able to sign an advanced directive (AD -legal document that outlines your wishes for medical care if you become unable to communicate them yourself) acknowledgement form for one of one sampled resident (Resident 40). This deficient practice violated Resident 40's and Resident 40's representative the right to be fully informed of the option to formulate an AD and had the potential to cause conflict with health care wishes for Residents 40. [...]

Inspectors wroteBased on interview and record review, for one of one sampled resident (Resident 4), the facility failed to ensure that Resident 40 and or the resident's representative were:1. Notified timely in writing the reason for the transfer/discharge to the hospital and send a copy of the notice to the ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities).2. Notified of the facility policy for bed hold (the facility agrees to keep a resident's bed available for them, even if they temporarily leave for a hospital stay or other leave of absence), including reserve bed payment in writing. This deficient practice resulted in Resident 4 and or the resident's representative not provided with options and rights regarding transfer and discharge by the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow through with the Preadmission Screening and Resident Review (PASARR- a federally required screening to help identify individuals with possible serious mental illnesses requiring a specialized follow up evaluation) recommendation to obtain a PASRR level II (assessment that determines if resident's mental condition could be met in the nursing facility or if the individual requires specialized services) evaluation for one of one sampled residents (Resident 18). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 18. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive resident specific care plan in accordance with the facility's policy and procedures (P&P) titled Care Plans, Comprehensive Person-Centered revised 1/16/2025 for one of one sampled resident (Resident 1). This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its policy regarding laundry hot water temperature monitoring on a daily basis. This deficient practice had the potential to result in the spread infection throughout the facility. During a concurrent interview and record review, on 7/17/2025, at 3:39 P.M., with the Laundry Aid (LA) 1, the facility's temperature log for 7/2025 for the washer, dryer, and sink was reviewed. LA 1 stated that the temperature log is used to document the washer temperature and the dryer temperature. LA 1 stated, the Dryer temperature is checked every two hours, and the washer is checked every time when we do a new cycle. LA 1 stated temperature checking and logging is done to make sure that the temperature is normal or the right temperature is used to wash and dry residents' clothes. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure rooms 2, 4, 6, 7, 8, 9, 11, 14, 16, 17, 18, 19, and 20 had no more than three residents and rooms [ROOM NUMBERS] had no more than six residents. This failure had the potential to have an adverse effect on the health and safety of the residents in rooms 1, 2, 4, 6, 7, 8, 9, 10, 11, 14, 16, 17, 18, 19, and 20 and impede the ability of any resident in the room to attain his or her highest practicable well-being. During an observation on 7/15/2025 at 2:03 PM in room [ROOM NUMBER], a total of six residents were in each room. During a concurrent interview Resident 32 stated he had no issues with his room and liked where he was. Resident 49 stated he had enough space for his belongings and did not have any complaints. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 15 of 20 resident rooms (rooms 1, 2, 4, 7, 8, 9, 10, 11, 14, 16, 17, 18, 19, and 20) met the space requirements of 80 square feet for each resident in multiple resident bedrooms. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the impacted residents. On 7/15/2025 at 1:50 PM during a general tour of the facility, Rooms 2, 4, 6, 7, 8, 9, 11, 14, 16, 17, 18, 19, and 20 were observed. room [ROOM NUMBER] and room [ROOM NUMBER] were observed with six residents each. The rooms were observed with enough space for nursing staff to provide care for the residents in the rooms. The rooms were observed with privacy curtains for each resident and with direct access to the corridors and the bathroom. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had a diagnosis of dementia (a progressive state of decline in mental abilities) was free from physical abuse (any intentional act causing injury or trauma to another person through bodily contact) and verbal abuse (abuse that involves the use of oral or written language directed to a victim, can include the act of harassing, labeling, insulting, scolding, rebuking, or excessive yelling towards an individual) by failing to: Ensure the facility's Security Guard (Sec 1) did not curse (using words in a negative or aggressive way to express anger, disrespect, or to cause distress) at Resident 1 and did not hit Resident 1 on the back of the head with an open hand on 6/19/2025 at approximately 9:40 PM. [...]

Inspectors wroteBased on interview and record review the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding risks, benefits and alternatives offered) for one of three sampled residents (Resident 1). For Resident 1, the facility failed to obtain informed consent from Resident 1 and Resident 1 ' s responsible party (RP) before administering the Haldol (medication used to treat certain mental/mood disorders) on 1/26/25. This deficient practice resulted in Resident 1 and Resident 1 ' s RP not given their right to know the risks and benefits of taking the Haldol and alternative treatment available.

Inspectors wroteBased on interview and record review the facility failed to ensure the medication administration was in accordance with the professional standard of practice for one of three sampled residents (Resident 1). For Resident 1, the facility failed to record the administration site when Resident 1 was given the Lantus (drug used to control the amount of sugar in the blood) 20 units subcutaneously (SQ, under the skin) during the month of 12/24. This deficient practice had the potential for Resident 1 to have the Lantus given SQ in the same injection site that could lead to skin damage.

Inspectors wroteBased on interview and record review the facility failed to reconcile (a process of reviewing complete medication regimen during admission, transfer or discharge) a physician order upon re-admission to the facility for one for three sampled residents (Resident 1). For Resident 1, the facility failed to continue the physician's order for Lantus (drug used to control the amount of sugar in the blood) 20 units subcutaneously (SQ, under the skin) once a day at bedtime when Resident 1 was re-admitted to the facility on [DATE]. This deficient practice resulted in Resident 1 not given the Lantus 20 units SQ for six days and had the potential for Resident 1 to suffer from hyperglycemia (high blood sugar).

Inspectors wroteBased on interview and record review the facility failed to implement measures to prevent loss of personal belongings for one of three sampled residents (Resident 1). For Resident 1, the facility failed to: 1. Ensure Resident 1's belongings list was reviewed and itemized to ensure all the personal belongings were given to Resident 1 when Resident 1 was discharged from the facility on 12/6/24. 2. Ensure the replacement hearing aids received by Resident 1 on 1/7/25 was an appropriate and correct fit for Resident 1. These deficient practices resulted in Resident 1 not given his right to keep his belongings secure while at the facility and to receive all the belongings when Resident 1 was discharged from the facility on 12/6/24.

Inspectors wroteBased on interview and record review the facility failed to develop and implement care plan for one of three sampled residents (Resident 1). For Resident 1 who had severe hearing loss on the left and right ears, the facility failed to: 1. Ensure Resident 1's care plan included appropriate interventions for Resident 1 who had severe hearing loss and needed hearing aids to hear clearly. 2. Address and provide appropriate interventions when Resident 1 constantly misplaced his hearing aids. Resident 1 lost his hearing aids on 5/7/24 and lost the replacement hearing aids on 9/26/24. These deficient practices had the potential for Resident 1 to have sensory deprivation and affect Resident 1's mental, physical, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident 1), who had severe cognitive impairment, had legally documented representation for decision making on behalf of the resident. This deficient practice caused Resident 1's rights to be violated as a resident living in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident 1), who had severe cognitive impairment, or the resident representative was informed and participated in the resident's care and treatment. This deficient practice caused Resident 1's rights to be violated as a resident living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure Staff 1 (the housekeeper) had proper documentation of a background check in the employee file as part of abuse prevention. This failure had the potential to result in an employee working at the facility with potential violations of abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 2), who was a known wanderer, received services to prevent accidents. Resident 2 was not supervised or monitored per the physician's order and the person centered care plan. This deficient practice caused an increased risk for accidents and injuries.

Inspectors wroteBased on observation and interview, the facility failed to provide a clean, free of odor, safe and home like environment by failing to ensure that: 1. One of seven sampled residents (Resident 2) had a home like environment free of offensive odors. 2. The kitchen staff had a safe and sanitary environment to work in. This deficient practice resulted in Resident 2 having feelings of disgust and feeling unheard as well as lead to a disruption in disruption of their duties.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse to the State Survey Agency, local law enforcement, and Ombudsman within two hours for one of five sampled residents (Resident 1). The deficient practice resulted in a delay of an on-site inspection by the State Survey Agency to ensure investigating Resident 1's allegation of abuse.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from abuse (deliberate, aggressive, or violent behavior with the intention to cause harm) for two of three sampled residents (Resident 5 and Resident 35). The facility failed to: -Ensure Resident 5 was free from physical abuse and was not struck in the face by Resident 206 with an open hand on 6/23/2024. -Prevent Resident 206 from splashing coffee onto Resident 35 on 6/3/2024, when Resident 206 had an aggressive behavior, was angry and upset. and splashed coffee onto another resident (Resident 35). These deficient practices resulted in Resident 5 and Resident 35 being subjected to abuse and psychosocial (mental health) harm by Resident 206, while under the care of the facility. Resident 5 asked the police to take Resident 206 away.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician responded to the consultant pharmacist's recommendation from 4/17/24 and 5/8/24, to justify the use of risperidone (a medication used to treat mental illness) in one of five sampled residents (Resident 8.) -Ensure the physician responded to the consultant pharmacist's recommendation from 3/18/24 to obtain an ammonia level (a lab value used to ensure certain medications are used safely) related to the use of divalproex sodium (anticonvulsant, a medication used to treat seizures) in one of five sampled residents (Resident 8.) -Ensure the physician responded to the consultant pharmacist's recommendation from 3/18/24, 4/17/24, and 5/8/24, to justify the use of quetiapine (Seroquel, a medication used to treat mental illness) in one of five sampled residents (Resident 35.) The deficient practice of failing to [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Four medication errors out of 26 total opportunities contributed to an overall medication error rate of 15.38 % affecting three of five residents observed for medication administration (Residents 19, 35, and 45.) The medication errors noted were as follows: -Administration of clonazepam (Klonopin, a controlled substance medication, sedative, used to treat mental illness) to Resident 45 without a Physician's Order. -Allowed Resident 19 to self-administer fluticasone nasal spray (Flovent, a medication used to treat allergies) without prior approval. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: -Discard and replace two expired insulin (a medication used to treat high blood sugar) pens affecting Residents 38 and 43 in one of two inspected medication carts (Medication Cart 2.) -Label one open bottle of latanoprost (a medication used to treat eye problems) with an open date affecting Resident 33 in one of two inspected medication carts (Medication Cart 1.) -Ensure an opened insulin (a medication is used to control high blood sugar) was not stored in the refrigerator per the manufacturer's requirements for Resident 26. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills as followed: a. Staff failed to verbalize when to perform hand hygiene, when going from dirty to clean area. b. Staff failed to verbalize proper dishwashing for air drying. c. Staff failed to verbalize how to check dish machine temperatures. d. Staff failed to verbalize and follow the manufacturer's guidelines of chlorine test paper (a type of test strip) when checking the chlorine (a chemical used to disinfect dishes) sanitizer concentration. e. Staff failed to demonstrate how to properly check Quaternary ammonium (QUAT, a chemical used to sanitize kitchen surfaces) sanitizer concentration based on manufacturer's instruction. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility menu when residents on a regular diet consistency (diets with no restriction) had no gravy on their trays. This deficient practice had the potential to cause a decrease in food intake resulting to unintentional (not done on purpose) weight loss to 39 of 45 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved appetizing temperatures when cold foods were in the danger zone (a range of temperature 41 degrees Fahrenheit ([°F], a scale of temperature) to 135°F in which bacteria grow rapidly) during trayline service. This deficient practice placed 44 of 45 facility residents at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen, including cross-contamination (transfer of harmful bacteria from one place to another), cleanliness of kitchen equipment, and hand hygiene. These failures had the potential to result in harmful bacteria growth and cross contamination which could lead to foodborne illness (transfer of bacteria from one object to another) in 44 of 45 medically compromised residents who received food and ice from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents do not self-administer medications without prior approval by allowing one of five residents observed for medication administration (Resident 19) to self-administer fluticasone (a medication used to treat allergies) nasal spray without an interdisciplinary team (IDT - a multi-discipline group of healthcare professionals involved in periodically meeting and planning care for individual residents) evaluation or a physician's approval. The deficient practice of allowing Resident 19 to self-administer medication without an IDT evaluation for safety or physician's order increased the risk that he may have administered the wrong dose of fluticasone due to poor technique possibly resulting in medical complications.

Inspectors wroteBased on interview and record review, the facility failed to report a resident-to-resident altercation to the State Survey Agency (SSA) within the appropriate time frame for two of three sampled residents (Resident 35 and Resident 206). This deficient practice resulted in a delay of onsite inspections by the Department of Public Health (DPH) and placed the residents at risks of further abuse (inappropriate treatment of an individual).

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a standardized assessment and carescreening tool) was transmitted timely to the Centers for Medicare and Medicaid Services (CMS) system for one sampled resident (Resident 29). This deficient practice had the potential to result in delayed services for the resident.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the minimum data set (MDS - a comprehensive resident assessment and care screening tool) assessment Section N (medications) on 3/28/24 by failing to indicate the resident's routine use of antipsychotic medication (medications used to treat mental illness) in one of five residents sampled for unnecessary medications (Resident 35.) The deficient practice of failing to accurately assess and indicate Resident 35's routine use of antipsychotic medication on the MDS comprehensive assessment Section N increased the risk that Resident 35 may not have received care planning and treatment according to his needs possibly leading to a decline in his overall health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan for one of two sampled residents (Resident 47) within 48 hours of resident's admission. This deficient practice had the potential for delayed administration of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to develop individualized comprehensive person-centered care plan to meet the resident's needs for two of five sampled residents (Resident 8 and Resident 26) as evidenced by: -Failing to create a comprehensive care plan to address problematic behaviors of auditory and visual hallucinations seeing and hearing voices of people that are not there related to the use of risperidone (a medication used to treat mental illness) for Resident 8. This deficient practice increased the risk that psychotropic medications (affect brain activities associated with mental processes and behavior) used to manage behaviors would not be periodically reevaluated as intended. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to update and revise the care plan for two of three sampled resident's (Resident 12 and Resident 27). For Resident 27 after the resident sustained a fall on 5/31/2024 and Resident 12's hospice care plan (specialized care that provides physical comfort and emotional, social, and spiritual support for people nearing the end of life) did not reflect current physician's orders and had no been updated for over 10 months. This failure resulted in Resident 27 sustaining another fall on 7/2/2024 and had the potential to result in Resident 12 receiving inadequate care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oral care to one of three sampled residents (Resident 12). Resident 12 had dry, cracked lips and did not receive oral care per the physician's order for 28 occurrences. This deficient practice had the potential for Resident 12 to develop a mouth infection and cause difficulty breathing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident 48) skin protective arm sleeve was applied. This failure resulted in Resident 48's left arm to swell and turn red.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the correct Low Air Loss Mattress (LALM, a mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) settings for one of three sampled residents (Resident 12). This deficient practice had the potential to lead to poor circulation (reduced blood flow to various body parts) and cause a pressure injury (localized skin and soft tissue injuries that form because of prolonged pressure and shear, usually exerted over bony prominence's) for Resident 12.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate supervision to prevent accidents for one of three sampled residents (Resident 27). Resident 27 did not receive frequent visual checks to monitor location, per the At Risk for Falls care plan. This failure resulted in the resident sustaining a fall on 5/31/24 and 7/2/24.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 47) maintained acceptable parameters of nutritional status by failing to obtain accurate weight and perform a nutritional assessment. This deficient practice had the potential to result in increased weight loss for Resident 47.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receiving respiratory care was in accordance with the physician's order for one sampled resident (Resident 48). Resident 48's oxygen flow rate was not set to the physician ordered 2 liters. This failure had the potential to result in Resident 48 experiencing shortness of breath and lower oxygen saturation (the amount of oxygen carried by the red blood cells).

Inspectors wroteBased on interview and record review, the facility failed to ensure staff competency evaluations were completed for one of three sampled Certified Nursing Assistants (CNA) 1. This failure had the potential for a knowledge, training, and certification deficit which could lead to inadequate resident care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately account for two doses of controlled medications (a high potential for abuse) affecting Residents 2 and 3 in one of two inspected medication carts (Medication Cart 1). This deficient practice increased the risk of diversion (any use other than that intended by the prescriber) of controlled mediations and that Residents 2 and 3 could have received too much or too little medication due to lack of documentation, possibly resulting in serious health complications requiring hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient documentation to support a diagnosis of seizure disorder in one of five residents sampled for unnecessary medications (Resident 8.) -Monitor valproic acid levels (a laboratory test used to ensure medications used to treat seizures are present at a safe and effect level in the blood) related to the use of divalproex sodium (a medication used to treat seizures) in one of five residents sampled for unnecessary medications (Resident 8.) The deficient practices of failing to sufficiently document a diagnosis of seizure disorder and monitor valproic acid levels related to the use of divalproex increased the risk that Resident 8 could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) or seizures related to valproic acid levels being too high or too low leading to [...]

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient documentation to support a diagnosis of schizophrenia (a mental illness characterized by seeing or hearing things that are not there) related to the use of risperidone (a medication used to treat mental illness) in one of five residents sampled for unnecessary medications (Resident 8.) The deficient practice of failing to ensure risperidone was only used to treat a medical condition as diagnosed and documented in the medical record increased the risk that Resident 8 could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to her medication therapy possibly leading to impairment or decline in her mental or physical condition or functional or psychosocial status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by not maintaining the trash area free from excess trash, plastic, empty plastic bottles, soiled gloves, and other dirt debris. This deficient practice had a potential to attract birds, flies, insects, pest and possibly spread infection to 44 of 45 facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a complete and accurate medical record by failing to record administered doses of clonazepam (Klonopin, a medication used to treat mental illness) for one of five sampled residents (Resident 45) observed for medication administration in the Medication Administration Record (MAR - a record of all medications administered, and monitoring performed for a resident) between 7/4/24 and 7/9/24. The deficient practice of failing to record administered doses of Klonopin in the MAR increased the risk that Resident 45 could have experienced medical complications related to administering Klonopin too frequently, possibly resulting in hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, comfortable environment for one sample resident (Resident 44). Resident 44's toilet seat was not secure which had the potential to place the resident at risk for injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the food services department when two flies were observed in the kitchen. This deficient practice had a potential to result in 44 of 45 residents, who received food from the kitchen, to acquire food borne illnesses (caused by consuming contaminated foods or beverages) by consuming potentially contaminated food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure room [ROOM NUMBER] and room [ROOM NUMBER] had no more than two residents. This failure had the potential to have an adverse effect on the health and safety of the residents in room [ROOM NUMBER] and room [ROOM NUMBER] and impede the ability of any resident in the room to attain his or her highest practicable well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 14 of 20 resident rooms (room [ROOM NUMBER], 2, 4, 6, 7, 8, 9, 10, 11, 14, 17, 18, 19, and 20) met the space requirements of 80 square feet for each resident in multiple resident bedrooms. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the impacted residents.

Inspectors wroteBased on interview and record review the facility failed to follow the physician order for one of two sample residents, Resident 1. The facility failed to carry out the physician order and transcribe the itraconazole (medication used to treat histoplasmosis (infection of the lungs caused by fungus [disease caused by mold] 200 milligrams (mg., unit of measurement) two times a day orally. On 3/19/24, the facility received an order from Resident 1 ' s general acute hospital (GACH 1) infectious disease physician (ID, medical doctor that specialized in in infectious diseases) to administer Resident 1 itraconazole 200 milligrams (mg., unit of measurement) orally three times a day for three days and followed by itraconazole 200 mg. orally two times a day. The facility administered the itraconazole 200 mg. orally three times a day for three days from 3/19/24 at 5 p.m. to 3/22/24 at 1 p.m. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive care plan for one of two sample residents (Resident 1). For Resident 1, the facility failed to develop a care plan that would address Resident 1's diagnosis of pulmonary histoplasmosis [fungal (yeast or mold) infection affecting the lungs [organs in the chest that control breathing]. This deficient practice resulted in facility failing to meet Resident 1's needs that would help Resident 1 attain his highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary care was consistently provided for one of three sampled residents (Resident 1), who was receiving hospice service (a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease, offers physical, emotional, social, and spiritual support for residents and their families), by failing to: -Ensure the hospice agency staff signed the hospice sign in sheet. -Obtain the most recent hospice plan of care. -Communicate with the hospice staff participating in the care of the resident to ensure quality care for the resident. These deficient practices had the potential to result in a delay of care and lack of coordination in delivery of hospice care and services to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of four sampled residents (Resident 2). By failing to ensure CNA3 who was assigned to monitor Resident 2 did not leave the resident unsupervised on 4/20/2024. As a result, Resident 1 punched Resident 2 with a closed fist in the face on 4/20/2024 at 7:15 P.M., after Resident 1 wandered into Resident 2 ' s room.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 5), who had no capacity to understand, had history of elopement (when the resident leaves the premises or a safe area without the facility's knowledge or supervision), and was at risk for wandering and elopement, received the care and supervision needed to prevent elopement by failing to: -Develop a person-centered, comprehensive care plan to include frequency of monitoring Resident 5's location through visual checks, per the At Risk of Elopement care plan. -Review Resident 5's elopement assessment form for accuracy, per the previous IJ removal plan approved on 2/29/2024. -Revise / Update Resident 5's At Risk for Elopement care plan to include monitoring every 15 minutes, per the previous IJ removal plan approved on 2/29/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop/and or implement a resident specific care plan (a document that outlines the facility ' s plan to provide personalized care to a resident based on the resident ' s needs) for one of four sampled residents (Resident 4) by failing to develop and implement a care plan to monitor and provide interventions for Resident 4 ' s Zyprexa (a medication to treat mental disorders) use. This failure had the potential to result in Resident 4 not being assessed and monitored for the side effects of Zyprexa which included dizziness, constipation, bladder pain, difficulty swallowing, and swelling of hands and feet.

Inspectors wroteBased on interview, and record review, the facility failed to protect the resident's rights and dignity for one of three sampled residents (Resident 1). On 3/4/2024, Resident 2 struck Resident 1 with a closed fist.

Inspectors wroteBased on interview and record review, the facility failed to ensure the discharge summary documented by the physician properly reflected the correct reason for discharge / transfer for one of three sampled residents (Resident 3). This deficient practice resulted in the inaccurate information conveyed upon discharge for Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure titled, Smoking Policy- Residents, and ensure a completed smoking assessment for one of three sampled residents (Resident 2). This deficient practice had the potential to lead to the inadequate care of Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to review and revise the Alteration in Psychosocial Well Being Care Plan for one of three sampled residents (Resident 1 ). This deficient practice had the potential to result in Resident 1 receiving inadequate care and supervision at the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe environment and supervision for one sampled (Resident 4), who was at risk for elopement (leaving the facility without notice or permission, presenting an imminent threat to resident's health and safety), at risk for wandering (a person with loss of memory, thinking, or reasoning roams around and becomes lost or confused about their location), and had diagnoses of schizophrenia (a mental illness that cause disturbed or unusual interest in life, and strong or inappropriate emotions; usually involves delusions [false beliefs], hallucinations [seeing or hearing things that don't exist]), and psychosis (a person loses contact with reality), to address Resident 1's history of elopement. The facility failed to: [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right and ensure residents were free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1). On 1/28/2024, Resident 2 hit Resident 1's face with an open hand. Resident 2, who was known to be aggressive, combative, would refuse her medications, with diagnoses including schizophrenia (a serious mental disorder in which people interpret reality abnormally, may result in delusions and behavior that impairs daily functioning) and refused her medications, did not receive monitoring, per the resident care plan. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 on 1/28/2024 while under the care of the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility Administration failed to provide effective leadership and oversight of processes and policies and procedures to ensure an effective system was in place to ensure Resident 4, who was known to have eloped twice from a previous facility, and all residents at risk for elopement (leaving the facility without notice or permission, presenting an imminent threat to resident's health and safety) did not elope from their facility. As a result, Resident 4 eloped from the facility on 2/22/2024. Resident was at risk of decline in physical, mental, and psychosocial condition due to interrupted medical care and medications, injury, pain, serious harm, or death. Resident had not been found nor returned to the facility as of 2/29/2024.

Inspectors wroteBased on interview and record review the facility failed to order physician prescribed medications from pharmacy and also failed to follow up on the ordered medications with the pharmacy for one of three sampled residents (Resident 1). The facility admitted Resident 1 on 12/12/23, ordered Resident 1 ' s medications on 12/13/23, and administered the medications to Resident 1 on 12/14/23. These deficient practices resulted in Resident 1 not receiving her medications for 24 hours from 12/13/2023 to 12/14/2023 which delayed the care and treatment to meet the needs of Resident 1.