Maple Springs Senior Living

Inspectors wroteBased on observation and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, food items in the refrigerator and freezer were undated, and sanitizer buckets did not meet the required sanitation testing levels.

Inspectors wroteBased on interview and record review, for 1 of 39 sampled residents, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice. Specifically, a resident was not provided crushed medications as ordered by the physician. Resident identifier: 64.

Inspectors wroteBased on interview and record review, the facility did not ensure each resident had supervision to prevent accidents. Specifically, for 2 out of 39 sampled residents, a resident was not secured in the facility van and tipped backwards sustaining a closed head injury. This example was cited at a harm level. Resident identifier: 73.

Inspectors wroteBased on observation and interview, the facility did not ensure that all drugs and biologicals were stored and labeled in accordance with accepted professional principles, under proper temperature controls and cautionary instructions, and the expiration date when applicable. Specifically, for 1 out of 39 sampled residents, a controlled drug was stored in a manner that failed to prevent potential drug diversion and ensure safe medication administration. Resident Identifier: 21.

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. Specifically, for 2 out of 39 sampled residents, one resident had a urinary catheter bag observed on the floor, and for a second resident receiving wound care, hand hygiene and glove changes were not performed. Resident identifiers: 2 and 9.

Inspectors wroteBased on interview and record review, it was determined for 1 of 5 sampled residents, that the facility failed to provide each resident with a safe diet that met the special dietary needs of each resident. Specifically, a resident had a diet order for moist and minced texture and was given a cheese stick and pretzels for a snack which resulted in the resident choking and passing away. Resident identifier: 1It was determined the provider's noncompliance with this rule caused harm. However, based on the facility's corrective actions and a review of its current compliance, the deficiency was determined to be past noncompliance. The facility developed and implemented a corrective action plan before the survey start date. The facility's corrective action plan, which was developed and implemented by December 3, 2025, included the following measures. [...]

Inspectors wroteBased on interview and record review it was determined, for 3 of 23 sampled residents, that the facility did not ensure that when the facility transferred or discharged a resident that the information provided to the receiving provided included: contact information of the practitioner responsible for the care of the resident; resident representative information including contact information; Advanced Directive information; all special instructions or precautions for ongoing care; all other necessary information, including a copy of the resident's discharge summary; and any other documentation to ensure a safe and effective transition of care. Specifically, residents were transferred to the hospital and no documentation could be found of the information that was provided to the receiving provider. Resident identifier 32, 39 and 93.

Inspectors wroteBased on observation and interview it was determined the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food in the refrigerator was not dated and labeled. In addition, there were soiled areas in the kitchen.

Inspectors wroteBased on interview and record review it was determined, for 1 of 23 sampled residents, that the facility did not consult with the resident's physician; and notify when there was a significant change in the resident's physical, mental, or psychosocial status. Specifically, a resident expressed feelings of suicidal ideation and the physician was not notified. Resident identifier 39.

Inspectors wroteBased on interview and record review it was determined, for 1 of 23 sampled residents, that the facility did not ensure that all alleged violations involving abuse and neglect were reported immediately, but not later than 2 hours after the the allegation was made to the administrator, State Survey Agency (SSA), and Adult Protective Services. Specifically, a resident eloped from the facility and the State Survey Agency was not notified. Resident identifier 39.

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 of 23 sampled residents, that the facility did not ensure that the resident received care, consistent with professional standards of practice, to prevent the development of pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable. Specifically, a resident developed a new pressure ulcer after admission to the facility and interventions were not implemented specific to the prevention of its development. Resident identifier: 23.

Inspectors wroteBased on interview and record review it was determined, for 1 out of 23 sampled residents, that the facility did not ensure that the resident environment remained as free of accident hazards was was possible and that the resident received adequate supervision to prevent accidents. Specifically, a resident who was identified as exit seeking did not have adequate supervision to prevent the resident from eloping. Resident identifier: 39.

Inspectors wroteBased on interview and record review it was determined, for 1 of 23 sampled residents, that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences. Specifically, a resident's medication was not administered per the physician ordered parameters. Resident identifier: 26.

Inspectors wroteBased on interview and record review it was determined, for 1 out of 23 sampled residents, that the facility did not ensure that residents who have not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. Specifically, a resident was prescribed an antipsychotic medication for insomnia. Resident identifier: 31.

Inspectors wroteBased on interview and record review, it was determined, that the facility did not provide or obtain laboratory services to meet the needs of its residents. Specifically, for 2 of 23 sampled residents, a urinalysis was not done as requested by the provider and a resident did not have ordered labs completed. Resident identifiers: 31 and 32.

Inspectors wroteBased on interview and record review it was determined, for 1 out of 23 sample residents, that the facility did not ensure that resident's laboratory reports were filed in the clinical record. Specifically, a resident's urine culture results were not in the resident's medical record. Resident identifier 32. Findings Included: Resident 32 was admitted to the facility on [DATE] with diagnoses that included, but not limited to, unspecified fracture of fifth lumbar vertebra, type 2 diabetes mellitus, paroxysmal atrial fibrillation, infection, and inflammatory reaction due to indwelling urethral catheter, severe sepsis, and personal history of urinary tract infections. Resident 32's medical record was reviewed on 11/14/23. A physician order dated 9/8/23 for a urinalysis and culture and sensitivity due to signs and symptoms of a UTI was reviewed. [...]

Inspectors wroteBased on interview and record review it was determined, for 1 of 23 sampled residents, that in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that was complete; accurately documented; readily accessible; and systematically organized. Specifically, a resident's physician's orders did not match the medication administered. Resident identifier: 26.

Inspectors wroteBased on interview and record review, it was determined, the facility did not establish an infection prevention and control program that included, an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. Specifically, for 1 out of 23 sampled residents, a resident with a Urinary Tract Infection (UTI) was treated with the incorrect antibiotic that was not listed on the susceptibility laboratory report. Resident Identifier: 32 Findings Included: Resident 32 was admitted to the facility on [DATE] with diagnoses that included, but not limited to, unspecified fracture of fifth lumbar vertebra, type 2 diabetes mellitus, paroxysmal atrial fibrillation, infection, and inflammatory reaction due to indwelling urethral catheter, severe sepsis, and personal history of urinary tract infections. [...]

Inspectors wroteBased on observation, interview and record review it was determined, for 3 of 23 sampled residents, that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including COVID-19. Specifically, an unvaccinated newly admitted resident on Transmission Based Precautions (TBP) did not isolate in their room for 14 days after admission and was allowed to exit the droplet isolation room to attend therapy services in the facility gym. Staff were observed not donning the appropriate Personal Protective Equipment (PPE) prior to entering rooms on droplet precautions, and did not sanitize their protective eyewear upon exit of droplet precaution rooms. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that medical records were complete, accurately documented, readily accessible and systematically organized for 3 of 23 sample residents. Specifically, hospice notes and physician visit notes had not been placed in the residents ' medical records. Resident identifiers: 17, 27 and 34.

Inspectors wroteBased on interview and record review it was determined, for 5 out of 5 sampled staff, that the facility did not conduct testing based on parameters set forth by the Secretary. Specifically, routine testing of unvaccinated staff members, based on community transmission, was not completed two times per week. Staff identifiers: Staff 1, Staff 2, Staff 3, Staff 4, and Staff 5.

Inspectors wroteBased on interview and record review it was determined that the facility did not ensure that 1 of 23 sample residents was seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. Specifically, a resident was not seen timely by a physician or physician surrigate. Resident identifier: