Maple Manor Care Center

Inspectors wroteBased on observation, record review, review of professional reference, and resident and staff interview, the facility failed to develop and provide an effective pain management regimen to meet resident needs for 2 of 14 sampled residents (Resident #4 and #5) reviewed for pain management. Failure to develop, implement, and provide an effective pain management plan resulted in unresolved pain and discomfort and decreased quality of life.

Inspectors wroteBased on review of a facility job description and staff interview, the facility failed to ensure 1 of 1 dietary manager (#11) obtained the proper qualifications to serve as the dietary manager. Failure to ensure staff have the qualifications to carry out the functions of a manager in the dietary department has the potential to result in foodborne illness to residents, staff, and visitors.

Inspectors wroteBased on review of the facility Quality Assurance and Performance Improvement (QAPI) program, review of the facility policy, and staff interview, the facility failed to ensure the Medical Director (physician) actively participated on the Quality Assurance (QA) committee for 3 of 4 quarters (July-September 2024, October-December 2024, and April-June 2025). Failure to ensure the medical director participates in the facility's QA activities deprived the committee of the physician's unique contribution for analyzing and correcting problems with identified resident care areas.

Inspectors wroteBased on observations and review of facility policy, the facility failed to serve food in accordance with professional standards for food safety in 1 of 2 dining rooms (north dining room). Failure to ensure no bare-hand contact with ready-to-eat food has the potential to result in a food borne illness.

Inspectors wroteBased on observation, record review, review of professional reference, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 14 sampled residents (Residents #4 and #5) observed during personal cares. Failure to practice infection control standards during medication administration and resident cares has the potential to spread infection throughout the facility.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the current status for 3 of 14 sampled residents (Resident #3, #11, and #32). Failure to review and revise the care plan as the needs change for the resident limited the ability of staff to communicate care needs and ensure continuity of care for each resident.

Inspectors wroteBased on observation, review of facility policy, review of professional reference, and staff interview, the facility failed to follow professional standards of practice for 2 of 3 sampled residents (Residents #3 and #5) observed during medication pass. Failure to disinfect the rubber seal of insulin pens increases the risk of infection to residents and failure to follow manufacturer instructions for eye drop administration may impede the effectiveness of the eye drops.

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to ensure 1 of 1 sampled resident (Resident #29) with contractures received the necessary devices. Failure to consistently provide a rolled washcloth to the resident's right hand may result in worsening of the contracture, pain, and further skin breakdown.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to properly utilize assistive devices for 1 of 4 sampled residents (Resident #16) reviewed for falls. Failure to properly use a bed and chair alarm placed the resident at risk for falls.

Inspectors wroteBased on observation, review of facility policy, and resident and staff interviews, the facility failed to serve foods at palatable temperatures on 2 of 3 days of survey (July 8-9, 2024). Failure to serve foods at a temperature acceptable to residents may result in decreased intake, weight loss, and inadequate nutrition.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to store food in a sanitary manner in 1 of 1 main kitchen. Failure to apply an identifying label to food and add an open date has the potential to affect food quality/preparation and may result in the spread of foodborne illness to residents, staff, and visitors.

Inspectors wroteBased on observation, record review, review of facility policy, confidential interview, and staff interview, the facility failed to provide resident care for 2 of 11 sampled residents (Resident #8 and #14) requiring assistance with activities of daily living in a manner that promotes, maintains, or enhances their quality of life. Failure to cover a urinary catheter leg bag (Resident #8) and failure to clean and shave resident's face and change the soiled shirt (Resident #14) has the potential to affect the resident's psychosocial well being and personal dignity.

Inspectors wrote1. Based on record review, review of facility policy, review of professional reference, and staff interview, the facility failed to follow professional standards of practice for 1 of 1 sampled residents (Resident #15) reviewed with orders for specific parameters for blood glucose levels. Failure to notify the physician of high blood glucose levels as ordered placed the resident at risk for delayed treatment and adverse health events.

Inspectors wroteBased on observation, record review, review of professional reference, and staff interviews, the facility failed to provide supervision to prevent accidents for 1 of 2 sampled residents (Resident #33) observed during a gait belt transfer. Failure to provide supervision of certified nurse aides (CNAs) by a licensed nurse regarding resident transfer assistance may result in unnecessary pain, falls and/or injury for residents.

Inspectors wroteBased on observation, record review, review of a professional reference, and staff interview, the facility failed to provide appropriate toileting for 1 of 6 sampled residents (Resident #33) who required staff assistance with toileting. Failure to provide toileting may result in a loss of dignity and placed the resident at risk for skin breakdown, poor grooming/hygiene, decreased self-esteem, urinary tract infections, and risk for fall and/or injuries.

Inspectors wroteBased on review of Medicare Part A letters/notices, Centers for Medicare and Medicaid Services instructions, and staff interview, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) form and Notice of Medicare Non-coverage (NOMNC) form two days in advance of discharge for 2 of 3 residents (Resident #23 and #38) discharged from Medicare Part A services. Failure to provide Medicare Part A letters/notices within the required time frame has the potential to limit the residents' right to an expedited review of service termination (NOMNC) and/or to exercise their rights to Medicare Part A services (SNFABN).

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to provide the resident or their representative and/or the State Long Term Care Ombudsman written notice of transfer for 1 of 4 residents (Resident #30) with a recent hospital transfer. Failure to provide a written copy of the transfer notice does not allow the resident and/or their representative to make an informed decision regarding their rights or inform the Ombudsman of the transfer.

Inspectors wroteBased on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 15 sampled residents (Resident #8 and #9). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents.

Inspectors wroteBased on record review, review of the North Dakota Provider Manual for Preadmission Screening and Resident Review (PASARR) and Level of Care Screening Procedures for Long Term Care Services, and staff interview, the facility failed to complete a status change assessment for 1 of 1 sampled resident (Resident #28) with a newly diagnosed mental illness. Failure to complete a change in status assessment may result in the delivery of care and services that are inconsistent with residents' needs.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise comprehensive care plans to reflect the current status for 3 of 15 sampled residents (Resident #8, #17, and #35). Failure to review and revise the care plan limited staffs' ability to communicate needs and ensure continuity of care.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the consultant pharmacist reported drug regimen irregularities for 2 of 5 sampled residents (Resident #18 and #25) selected for drug regimen review. Failure to report drug regimen irregularities and act upon recommendations may result in residents receiving unnecessary medications and experiencing adverse consequences related to their use.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to ensure a medication regimen free from unnecessary medications for 2 of 5 sampled residents (Resident #18 and #25) selected for medication regimen review. Failure to attempt a gradual dose reduction (GDR) or identify contraindications for a GDR may result in residents receiving unnecessary medications and experiencing adverse consequences related to their use.

Inspectors wroteBased on review of Quality Assurance and Performance Improvement (QAPI) meeting minutes, facility policy, and staff interview, the facility failed to ensure participation by the medical director for 1 of 3 quarterly meetings (May 9, 2023) reviewed.

Inspectors wroteHAND HYGIENE 1. Based on observation, review of professional reference, and staff interview, the facility failed to follow standards of infection control for 1 of 4 sampled residents (Resident #24) observed while receiving toileting assistance. Failure to follow infection control practices regarding hand hygiene during cares has the potential for transmission of communicable diseases and infections to residents, staff, and visitors.