Maple Park Village

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the residents' right to be free from physical abuse by a CNA for 2 of 3 residents reviewed for abuse. (Resident D and F) This deficient practice resulted in Resident D thinking a staff member was going to kill him and signs he was scared after the abuse. Resident F had a history of abuse as a child and had two loose teeth in her mouth. The deficient practice was corrected on 2/20/26, prior to the start of the survey, and was therefore past noncompliance.

Inspectors wroteBased on interview and record review, the facility failed to ensure a medication was held according to the ordered parameters and the physician was notified of blood glucose readings as ordered for 2 of 5 residents reviewed for quality of care. (Resident 7 and 6)

Inspectors wroteBased on interview and record review, the facility failed to ensure physician ordered medications included an appropriate supporting diagnosis and a medication included a stop date for 3 of 5 residents reviewed for unnecessary medications. (Resident 11, 5 and 13)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff wore Personal Protective Equipment (PPE) properly, wore the appropriate PPE when entering an isolation room, preformed hand hygiene, and changed gloves during a dressing change for 3 of 7 residents reviewed for infection control. (Resident 57, 34 and 5)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with continuous feeding through a Jejunostomy tube (J-tube) received the ordered amount of nutrient formula at the correct rate in the ordered time frame for 1 of 2 residents reviewed for enteral feedings. (Resident B) The deficient practice was corrected on 10/15/24, prior to the start of the survey, and was therefore past noncompliance.

Inspectors wroteBased on interview and record review, the facility failed to conduct care plan meetings at least quarterly for 2 of 2 residents reviewed for care plan conferences/meetings. (Resident 5 and 59)

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were held according to the physician's ordered hold parameters for 2 of 2 residents reviewed for quality of care. (Resident 36 and 55)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure unlabeled food was not stored in a medication room refrigerator and medications were stored in the original containers in 1 of 2 medication rooms and 1 of 3 medication carts reviewed for medication storage. (200 hall refrigerator and 300 hall medication cart)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff prepared pureed food in a sanitary manner for 1 of 1 staff member observed to puree food. (Cook 6)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a narcotic pain patch was administered at the correct time and new sites were used for the transdermal patch administration for 1 of 1 resident reviewed (Resident B) and failed to ensure staff were signing the narcotic count sheets for 4 of 6 medication cart narcotic logs reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received non-disposable utensils to eat their meals with for 17 of 17 residents reviewed for dining on the locked dementia unit.

Inspectors wroteBased on interview and record review, the facility failed to give medications within the prescribed time for 6 of 6 residents reviewed for quality of care. (Residents B, C, D, E, F, G)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment included the resident had a wanderguard for 1 of 1 resident reviewed for elopement. (Resident E)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with a wanderguard (an alarm bracelet) had a physician's order, daily assessment for placement and a care plan for the alarm for 1 of 1 resident reviewed for elopement. (Resident E)

Inspectors wroteBased on interview and record review, the facility failed to identify and implement resident specific preventative nursing measures for a resident with multiple repeat urinary tract infections (UTI) for 1 of 3 residents reviewed for UTIs. (Resident F)

Inspectors wroteBased on observation, interview and record review, the facility failed to identify significant weight changes, implement timely interventions, and notify the provider and family in a timely manner for 2 of 4 residents reviewed for nutrition. (Resident 31 and E)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents oxygen tubing was dated and replaced for 2 of 3 residents reviewed for respiratory care. (Residents 38 and 76)

Inspectors wroteBased on record review and interview, the facility failed to ensure symptom monitoring was in place for the use of an antipsychotic medication prescribed and a gradual dose reduction (GDR) was considered for 1 of 5 residents reviewed for unnecessary medications. (Resident F)

Inspectors wroteBased on observation, interview and record review, the facility failed to label medications with an open date on medications with a shortened expiration date once opened in 1 of 2 medication storage refrigerators and 2 of 3 medication carts (300 Unit, 100 Unit and 300 North Unit).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a catheter bag was not touching the ground for 1 of 1 resident reviewed for infection control related to catheters. (Resident 14)

Inspectors wroteBased on interview and record review, the facility failed to protect a resident from injury when the resident was left unattended in a bed which was not in the lowest position, and without a fall mat on the floor. The resident fell out of bed, sustained a laceration to the left side of the forehead and an acute left femoral neck fracture (a type of hip fracture of the thigh bone, just below the ball of the ball-and-socket hip joint). (Resident B) The facility also failed to ensure staff providing care were using/following the care sheet or electronic record which provides information on safety precautions put in place, resulting in Resident C had to be lowered to the floor, for 2 of 3 residents reviewed for accidents. (Resident B and C) The deficient practice was corrected on 9/12/23, prior to the start of the survey, and was therefore past noncompliance.