Maple Heights Nursing & Rehabilitative Center

Inspectors wroteThe facility identified a census of 50 residents. The sample included three residents with three residents reviewed for hot liquid safety. Based on observations, record review, and interviews, the facility failed to ensure an environment free from accident hazards when on 02/15/26 Dietary Staff CC provided cognitively impaired Resident (R) 1 with coffee in a lidded cup, without obtaining the temperature of the coffee prior to giving it to her, and R1 spilled the coffee on herself. After the spill, the staff obtained the temperature of the coffee, which was 151 degrees Fahrenheit. R1 sustained second degree burns from the hot liquid spill.

Inspectors wroteThe facility had a census of 44 residents. The facility had one kitchen. Based on observation, interview, and record review the facility failed to prepare, store, distribute, and serve food under sanitary conditions for the 44 residents in the facility, who receive their meals from the kitchen. This deficient practice placed the residents of the facility at risk for food borne illness.

Inspectors wroteThe facility had a census of 44 residents. The sample included 15 residents. Based on observation, interview, and record review, the facility failed to notify the State Long Term Care Ombudsman (LTCO), Resident (R)9's and R15's facility-initiated discharge to the hospital. This placed the residents at risk for impaired rights.

Inspectors wroteThe facility had a census of 44 residents. The sample included 15 residents with one reviewed for pressure ulcers. Based on observation, record review, and interview, the facility failed to initiate effective interventions to prevent the development of a left heel, facility acquired, unstageable pressure ulcer (depth of the wound is unknown due to the wound bed being covered by a thick layer of other tissue and pus,) for Resident (R) 9.

Inspectors wroteThe facility had a census of 44 residents. The sample included 15 residents, of which five were reviewed for medication use. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identify and report Resident (R) 39's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication had an approved indication for use. This placed the residents at risk for inappropriate use of medication.

Inspectors wroteThe facility had a census of 44 residents. The sample included 15 residents, of which five were reviewed for medication use. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identify and report Resident (R) 39's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication had an approved indication for This placed the residents at risk for inappropriate use of medication.

Inspectors wroteThe facility had a census of 31 residents. Based on observation, interview, and record review, the facility failed to label Resident (R) 12 and R31s' insulin (a hormone that lowers the level of glucose in the blood) flex pens when started in use and when expired. This deficient practice placed the affected residents at risk for ineffective medications.

Inspectors wroteThe facility had a census of 44 residents. Based on observation, record review and interview the facility failed to provide a safe, sanitary environment for Resident (R) 15 when staff failed to clean his carpet and recliner.

Inspectors wroteThe facility identified a census of 36 residents with one kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to storage of food. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns.

Inspectors wroteThe facility had a census of 36 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to secure chemicals in a safe, locked area, and out of reach of the nine cognitively impaired, independently mobile residents. The facility additionally failed to identify and implement resident centered fall intervention for Resident (R)20's repeated falls and failed to ensure implemented interventions identified during some investigations were added to the R20's plan of care. The facility further failed to prevent an avoidable accident when staff failed to ensure the floor was dry prior to a transfer, resulting in a fall for R18. This placed the affected residents at risk for preventable accidents and related injuries. Findings Included: [...]

Inspectors wroteThe facility reported a census of 36 residents. Based of observations, record review, and interviews, the facility failed to ensure safe storage and handling of the resident's medications. This deficient practice placed the residents at risk for unnecessary medication and administration errors. Findings Included: - On 06/13/23 at 07:02AM a medication treatment cart outside Resident (R)10's room contained a Novolog Flexpen (injectable short-acting hormone which regulates blood sugar) left unsecured on top of the cart from 07:02AM to 07:10AM. The insulin belonged to R10. At 07:10AM Licensed Nurse (LN) G returned to the cart and secured the pen. On 06/15/23 at 12:34PM Licensed Nurse (LN) G stated medication should be secured when not being immediately administered or supervised. He stated staff should locked up medication in the cart when stepping away from the cart. [...]

Inspectors wroteThe facility identified a census of 35 residents. Based on observations, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to clean supply storage, respiratory equipment, shared care equipment, hand hygiene during medication administration, and providing cares. This deficient practice placed the residents at risk for complications related to infectious diseases. Findings Included: - On 06/13/23 at 07:10AM an inspection of the 100-hallway shower room revealed three opened packages of incontinence briefs stored on a shelf above the toilet. The content of packages (incontinence briefs) was pulled out of the plastic wrapper and stored directly on the shelf. On 06/13/23 at 08:01 AM Laundry Staff V stated she obtained water temperature daily but only recorded the temperature weekly. [...]

Inspectors wroteThe facility identified a census of 36 residents. The sample included 12 residents with one resident reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed provide written notice of transfer with the required information to Resident (R) 90 and/or to their legal representative in a practicable amount of time. The facility also failed to send notification to the office of the state Long-Term Care Ombudsman of the facility's transfers and discharges. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare service for these residents.

Inspectors wroteThe facility identified a census of 36 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to ensure a care plan area was initiated to address Resident (R) 2's limited range of motion (ROM) due to contracture (an abnormal permanent fixation of a joint) of her joints, bilateral upper and lower extremities, and neck to maintain her current level of ROM and promote comfort. This deficient practice placed R2 at risk for decreased ROM and impaired comfort.

Inspectors wroteThe facility identified a census of 36 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to ensure Resident (R) 28 had interventions in place to promote healing of a pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). This deficient practice placed R28 at risk for delayed healing and additional skin breakdown.

Inspectors wroteThe facility identified a census of 36 residents. The sample included 12 residents. Based on observation, record review and interview, the failed to ensure a restorative program was provided to Resident (R) 2, who had limited range of motion (ROM) due to contracture (an abnormal permanent fixation of a joint) of her joints, to maintain her current level of ROM and promote comfort. This deficient practice placed R2 at risk for decreased ROM and impaired comfort.

Inspectors wroteThe facility identified a census of 36 residents. The sample included 12 residents with four reviewed for bowel and bladder management. Based on observation, record review, and interviews, the facility failed to implement individualized toileting interventions related to bowel and bladder incontinence for Residents (R)17 and provide sanitary Foley catheter (tube inserted into the bladder to drain urine into a collection bag )care for R10. This deficient practice placed the residents at risk for complications related to infection and incontinence. Findings Included: [...]

Inspectors wroteThe facility identified a census of 36 residents. The sample included 12 residents with two reviewed for respiratory care. Based on observation, record review, and interviews, the facility additionally failed to date and store Resident (R)35's supplemental oxygen equipment (masks and tubing) in a sanitary manner. This deficient practice placed R35 at risk for complications related to respiratory care and infections. Findings Included: [...]

Inspectors wroteThe facility identified a census of 36 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to ensure nurse aid staff possessed the competency and skills necessary to care for residents' catheters (a tube placed into the bladder to drain urine into a collection bag). This deficient practice placed the affected residents at risk for catheter related urinary tract infection (UTI-an infection of the organs of the urinary tract) or other urinary system complications.

Inspectors wroteThe facility identified a census of 36 residents. The sample included 12 residents with six residents sampled for unnecessary medications. Based on observation, record review and interview the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the lack of staff monitoring Resident (R) 36 for side effects and behaviors associated with the use/administration of the antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) medication mirtazapine. These deficient practices placed R38 at risk of unnecessary mediation administration and potential adverse side effects.

Inspectors wroteThe facility identified a census of 36 residents. The sample included 12 residents with six residents sampled for unnecessary medications. Based on observation, record review and interview the facility failed to ensure that staff monitored Resident (R) 36 for side effects and behaviors associated with the use/administration of the antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) medication mirtazapine. This deficient practice placed these resident at risk of unnecessary mediation administration and adverse side effects.

Inspectors wroteThe facility identified a census of 36 residents. The sample included 12 residents with five residents reviewed for reviewed for vaccination status. Based on record reviews, and interviews, the facility failed to obtain influenza (highly contagious viral infection that attacks the lungs, nose, and throat and can be deadly in high-risk groups) vaccination consent, declination, or administration information for Resident (R) 35. This deficient placed R35 at increased risk for influenza and related complications.

Inspectors wroteThe facility identified a census of 36 residents. The sample included 12 residents with five residents sampled for COVID-19 (an acute respiratory illness in humans caused by coronavirus, capable of producing severe symptoms and in some cases death) vaccinations. Based on record review and interviews, the facility failed to obtain signed consents or declinations for COVID-19 vaccinations for Resident (R) 35. This deficient practice placed the resident at increased risk for COVID-19.

Inspectors wroteThe facility identified a census of 44 residents. The facility had two medication storage rooms. Based on observation, record review and interview, the facility failed to ensure medications were stored properly in one of the two medication storage rooms. This placed residents at risk for decreased medication effectiveness and unnecessary side effects. Findings Included: - On 11/02/2021 at 07:40 AM observation revealed the medication storage refrigerator which contained controlled substances (drugs which have a high abuse risk) was not locked. The following medications were present: [...]

Inspectors wroteThe facility identified a census of 44 residents. The sample included 15 residents, with five residents sampled for medication review. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified a blood pressure medication order for Resident (R)35 lacked a pulse parameter ordered by the physician or documentation of the pulse , and blood pressure and pulse reading for R13 was not documented. This deficient practice had the potential risk for unnecessary medication and unwarranted side effects for those two sampled residents.

Inspectors wroteThe facility identified a census of 44 residents. The sample included 15 residents, with five residents sampled for medication review. Based on observation, record review, and interview, the facility failed to ensure that a pulse was obtained and documented for Resident (R)35's metoprolol tartrate (a medication used to control heart rhythm, treat chest pain, and reduce blood pressure) prior to administration; and blood pressure and a pulse reading for R13 was not documented prior to administration of carvedilol (a medication used to high blood pressure and heart failure). This deficient practice had the potential risk for unnecessary medications and unwarranted side effects for those two sampled residents.