Maple Hills Skilled Nursing & Rehabilitation

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interview, review of a facility self reported incident form, and review of a facility job description, the facility failed to ensure staff implemented the assistance devices necessary to prevent accidents. This affected one resident (#35) of five sampled residents. The facility census was 34.

Inspectors wroteBased on review of the facility's cycle menu, review of food temperature logs, staff interview, and policy review, the facility failed to ensure residents received food that was procured from their food service supply company and was prepared in the facility's kitchen to ensure proper food handling and preparation to safe guard it from possible food-borne illnesses. This affected eight (Resident #5, #6, #11, #20, #22, #24, #31, and #35) out of 36 residents who resided in the facility.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of a facility self-reported incident (SRI), and staff interview, the facility failed to ensure pre-operative laboratory testing was completed for a resident that was scheduled to have a surgical procedure performed to address kidney stones. This affected one (Resident #38) of two residents reviewed for pre-operative surgical procedures.

Inspectors wroteBased on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure fall interventions were in place per the plan of care and failed to ensure a fire blanket was available in the designated smoking area. This affected one resident (#8) out of the two residents reviewed for falls and had the potential to affect the seven residents (#1, #4, #8, #13, #17, #18, and #29) identified by the facility as smoking in the designated smoking area. The facility census was 32.

Inspectors wroteBased on observation, interviews and completion of a facility provided meal test tray the facility failed to provide palatable meals at the appropriate temperature. This affected all thirty-one residents who receive their meals from the kitchen with the exception of one resident (#20), who does not receive them. The facility census was 32.

Inspectors wroteBased on observation and interviews the facility failed to maintain all kitchen equipment in a clean, serviceable, and operational manner. This affected all residents who received meals from the kitchen with the exception of one resident (#20) who did not receive them. The facility census was 32.

Inspectors wroteBased on observations, staff interviews, resident record reviews, and review of facility policy, the facility failed to ensure residents dignity was maintained while providing assistance with consuming meals. This affected one resident (#19) observed during dining experiences. The facility census was 32.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure a baseline care plan was implemented for a resident with a tracheostomy or requiring respiratory care. This affected one resident (Resident #186) out of twelve residents reviewed for baseline care plans. The facility census was 32.

Inspectors wroteBased on observations, staff interviews, and record reviews, the facility failed to ensure comprehensive care plans were accurately completed for residents who smoked. This affected two residents (#4 and #8) reviewed for smoking. The facility identified seven residents (#1, #4, #8, #13, #17, #18, #29) who resided in the facility and smoked. The facility census was 32.

Inspectors wroteBased on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure residents who were dependent on staff for nail care and meal assistance received care in a timely and appropriate manner. This affected two residents (#2 and #19) out of the three residents reviewed for Activities of Daily Living (ADLs). The facility census was 32.

Inspectors wroteBased on interviews, record review, and facility policy, the facility failed to ensure dialysis communication forms were utilized to ensure communication between the facility and the dialysis center. This affected one resident (#16) of one resident reviewed for dialysis. Facility census was 32. Review of Resident #16's medical record revealed an admission date of 07/23/24. Medical diagnoses included osteomyelitis, diabetes mellitus type 2, severe calorie malnutrition, alcoholic cirrhosis of liver without ascites, end stage renal disease, anxiety, anemia, dependence on dialysis, right below the knee amputation, thrombocytopenia, and atrial fibrillation. Review of Resident #16's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitively intact, dependent for toilet and tub/shower transfers, and required assistance for mobility and was wheelchair dependent. [...]

Inspectors wroteBased on observation, review of an invoice from an outside plumbing company, review of maintenance temperature logs, and staff interview, the facility failed to ensure hot water temperatures were maintained between 105 degrees Fahrenheit (F.) and 120 degrees F. as required and did not pose a potential burn risk for the residents. This had the potential to affect seven residents (#2, #7, #10, #18, #20, #21, and #26), who the facility identified as having the use of the first floor shower room and five residents (#8, #9, #22, #25, and #28), who the facility identified as having the ability to utilize the sinks in their rooms on the second floor, without staff assistance.

Inspectors wroteBased on observation, record review, staff interviews, resident interviews, Ombudsman electronic communication, and policy review, the facility failed to provide sufficient staff to meet residents' needs. This affected three residents (#24, #28, and #30) of three residents reviewed for personal care needs and had the potential to affect all 33 of 33 residents in the facility.

Inspectors wroteBased on record review, review of the administrator's job description, observations, review of the facility vendor and supplier bills, and interviews, the facility failed to ensure the facility was administered in a manner that enabled it to use it's resources effectively and efficiently including compliance with all financial obligations for the delivery of care to attain and maintain the highest practicable well being of each resident. This affected 33 of 33 residents residing in the facility.

Inspectors wroteBased on observation, policy review, and interview, the facility failed to ensure the facility provided a safe, sanitary and comfortable environment for residents. This affected 33 of 33 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident medical record documentation was accurate and not falsified. This affected three residents (#24, #26, and #28) of three sampled residents reviewed for accurate medical records.

Inspectors wroteBased on observation, record review, review of the Administrator job description and personnel file and interview, the facility failed to employ a qualified administrator to ensure the facility was effectively and efficiently administered to allow all residents to attain or maintain their highest practicable physical, mental, and psychosocial well-being and to ensure staff were knowledgeable of who the administrator was. This had the potential to affect all 34 residents residing in the facility. Findings Include: On [DATE] between 10:45 A.M. and 12:41 P.M. interviews with Certified Nursing Assistant (CNA) #216, Licensed Practical Nurse (LPN) #223, and Registered Nurse (RN) #220 revealed none of the staff knew who the current facility Administrator was. The staff revealed they were not familiar with Interim Administrator (IA) #260 or Administrator #275. [...]

Inspectors wroteBased on observation, record review, facility policy review and interview, the facility failed to maintain a safe, functional and comfortable environment for all residents and failed to timely address an alarming carbon monoxide detector to ensure resident safety. This had the potential to affect all 34 residents residing in the facility. The facility census was 34. Findings Include: Review of the Fire Department Run Report dated 02/08/25 revealed the fire department was dispatched to the facility at 9:10 A.M. for a possible gas or carbon monoxide (CO) leak at the facility. There was no gas detected on the first floor of the facility but upon entering the basement, the multi-gas meter started alarming with carbon monoxide level at 87 parts per million (ppm) (normal/average levels 0.5-5.0 ppm). Evacuation and ventilation procedures were started. [...]

Inspectors wroteBased on observation, record review, facility policy review and staff interview, the facility failed to ensure all essential mechanical equipment (boiler) was maintained in a functional and safe operating condition. The had the potential to affect all 34 residents residing in the facility. Findings Include: Review of the boiler inspection dated [DATE] revealed Certificate of Operation expired: The Certificate of Operation is expired due to either a non-passed inspection within the last 12 months or non-payment of fees. Please contact the Division of Industrial Compliance support staff within 30 days of this order. Observation on [DATE] at 11:58 A.M. of the boiler room revealed the boiler had a red tag on it dated [DATE]. Boiler needs serviced was written on the tag. [...]

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure food was prepared and served in a sanitary manner. This had the potential to affect all residents that received meals from the facility's kitchen. The facility's census was 30.

Inspectors wroteBased on record review and interview, the facility failed to ensure Pre-admission Screening and Resident Reviews (PASARRs) were accurate, updated, and new mental health diagnoses were sent for a Level II review. This affected four residents (#6, #8, #11, and #13) of four residents reviewed for PASARRs. The facility census was 30.

Inspectors wroteBased on observation, review of the menu's spreadsheet, staff interview, and policy review, the facility failed to ensure appropriate serving sizes were provided in accordance with the facility's menu's spreadsheet. This affected 19 residents (#1, #3, #4, #5, #6, #8, #9, #11, #13, #14, #15, #17, #18, #21, #26, #29, #31, #32, and #136) who the facility identified as receiving regular/ no added salt/ and carbohydrate controlled diets.

Inspectors wroteBased on observation and interview, the facility failed to maintain the floors in a safe manner that prevents fall hazards and keeping a homelike environment. This had the potential to affect three residents (#23, #32, and #135). The facility census was 30.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to provide written notice of discharge to Resident #34 and the ombudsman. This affected one resident (#34) of two residents reviewed for discharge. The facility census was 30.

Inspectors wroteBased on record review, observation, staff interview, and policy review, the facility failed to ensure a resident who was dependent on staff for personal care received the assistance needed with nail care. This affected one resident (#12) of two residents reviewed for activities of daily living (ADL's).

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure a resident who was receiving hospice services had relevant hospice related records (Comprehensive Assessments and Plan of Care and visit notes) readily accessible and part of the resident's medical record to ensure continuity of the resident's care. This affected one resident (#20) of one resident reviewed for hospice services.

Inspectors wroteBased on record review and interview, facility failed to ensure new fall prevention interventions were established post-fall for two residents. This affected two residents (#24 and #32) of two residents reviewed for falls. The facility census was 30.

Inspectors wroteBased on record review, resident interview, staff interview, and policy review, the facility failed to ensure residents, who were identified as having had significant weight loss, had new nutritional interventions implemented timely to address their known weight loss. This affected two residents (#9 and #24) of two residents reviewed for nutrition.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure artificial nutrition via gastrostomy tube (g-tube) was completed per professional standards. This affected one resident (#135) of one resident reviewed for tube feeding. The facility census was 30.

Inspectors wroteBased on observation, record review, resident and staff interview, the facility failed to ensure a resident, who was displaying signs of a depressed mood, received an antidepressant as ordered by the physician. This affected one (Resident #78) of two residents reviewed for mood and behaviors. Actual harm occurred to Resident #78 when the facility failed to administer ordered antidepressant medication and antianxiety medication resulting in the resident expressing thoughts of being depressed, sleeping for extended periods of time, and being tearful when being conversed with.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure a clean and sanitary kitchen. This had the potential to affect all residents residing in the facility.

Inspectors wroteBased on observation, staff interview, and medical record review the facility failed to ensure a resident was treated with dignity and respect when the resident's soiled clothing was not changed and the resident was in a public area. This affected one resident (Resident #4) of three sampled residents reviewed for dignity.

Inspectors wroteBased on medical record review and staff interview the facility failed to conduct an admission comprehensive assessments within 14 calendar days as required. This affected two residents (Resident #228 and Resident #229) of 13 sampled residents.

Inspectors wroteBased on medical record review and staff interview the facility failed to assess residents once every three months as required. This affected three sampled residents (Resident #2, Resident #4, and Resident #18) of 13 sampled residents.

Inspectors wroteBased on record review, observation, staff interview and policy review, the facility failed to ensure residents' complete comprehensive care plans included care plans for respiratory care and pain. This affected two (Resident #22 and #25) of 15 residents reviewed for care plans.

Inspectors wroteBased on record review, resident interview, staff interview, and policy review, the facility failed to ensure residents and/ or their representatives were invited to attend care planning conferences to be a part of the development of their plan of care. This affected two (Resident #18 and #78) of four residents reviewed for care planning.

Inspectors wroteBased on record review, resident interview and staff interview, the facility failed to ensure a resident, who was dependent on staff for assistance with personal care, received the assistance needed to be able to receive showers as she desired. This affected one (Resident #78) of three residents reviewed for activities of daily living (ADL's).

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to ensure residents were properly positioned during meals and a resident was in an appropriate size wheelchair to allow her feet to come into contact with the floor and not dangle while she was sitting in the wheelchair. This affected two (Resident #4 and #23) of three residents reviewed for positioning.

Inspectors wroteBased on record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure fall prevention interventions were implemented as per the plan of care for a resident with a known history of falls. This affected one (Resident #78) of three residents reviewed for falls.

Inspectors wroteBased on observation, medical record review, resident interview, and staff interview the facility failed to provide an ordered therapeutic diet and failed to maintain a resident's nutritional status. This affected one resident (Resident #18) of one sampled residents reviewed for nutrition.

Inspectors wroteBased on observation, record review, and resident and staff interviews, the facility failed to provide respiratory care consistent with professional standards of practice when two residents were receiving oxygen that was outside of the physician ordered parameters. This affected two of four residents (Residents #24 and #26) reviewed for respiratory services.

Inspectors wroteBased on observation, staff interview, and medical record review the facility failed to conduct an assessment of a resident's bed rails and did not have evidence of maintaining a resident's side rail. This affected one Resident (Resident #18) of two sampled residents reviewed for accidents.

Inspectors wroteBased on medical record review and staff interview the facility failed to provide medically related social services after the death of a resident's child. This affected one resident (Resident #18) of 13 sampled residents.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a resident's indication for use of a pain medication was clear and a resident had adequate monitoring for medications by obtaining laboratory testing as ordered. This affected two residents (Resident #18 and Resident #229) of five sampled residents reviewed for unnecessary medications.

Inspectors wroteBased on staff interview and medical record review the facility failed to identify and track a resident's target behaviors when the resident received an antianxiety and antidepressant medication. This affected one sampled resident (Resident #18) of five sampled residents reviewed for unnecessary medications.