Maple Valley Nursing Home

Inspectors wroteBased on interview and record review, the facility failed to report Payroll Based Journal (PBJ) information to CMS (Centers for Medicare and Medicaid). This deficient practice resulted in inaccurate reporting of staffing levels with the potential to affect all residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure Medication Regimen Reviews were completed and addressed by the attending physician in the medical records of four Residents (#8, #2, #3, & #7) of five residents reviewed for unnecessary medications.

Inspectors wroteThis deficiency pertains to Intake #2792749Based on interview and record review, the facility failed to protect a resident from misappropriation of resident property for one Resident (#21) of one resident reviewed for misappropriation of property.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Long-Term Care Ombudsman was notified of a resident's discharge from the facility for one Residents (#25) of one resident reviewed for discharge practices.

Inspectors wroteBased on interview and record review, the facility failed toMaintain documentation in the clinical record to support a new diagnosis of schizophrenia, Care plan and provide interventions for schizophrenia, Monitor for behaviors associated with schizophrenia consistent with Diagnostic and Statistical Manual of Mental Disorders criteria, andMonitor for antipsychotic side effects and adverse reactionsfor one Resident (#3) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to:Document wound monitoring and assessments for one Resident (#21) of two residents reviewed for skin conditionsMaintain documentation in the facility reflecting ongoing collaboration and communication between the facility and hospice provider and ensure an updated hospice plan of care was retained in the facility for one Resident (#12) of three residents reviewed for hospice care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician's order for supplemental oxygen and ensure respiratory equipment was changed and labeled for one Resident (#12) of two residents reviewed for oxygen therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and served food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among any and all 21 residents of the facility.

Inspectors wroteThis deficiency contains two deficient practices: Deficient Practice #1 Based on interview and record review, the facility failed to establish and/or implement an Infection Prevention and Control Program (IPCP) and update IPCP policies annually. This deficient practice had the potential to affect all 21 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a dignified dining experience for three Residents (R5, R7, and R18) of twenty-one residents reviewed for dining experience. This deficient practice resulted in frustration and helplessness for those residents who were waiting for their meal to arrive.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the assessment of respiratory status prior to the administration of an inhaled medication and according to professional standards for one Resident (#18) of five resident reviewed for medication administration.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' code status was communicated and readily available for staff in the event of an emergency for three Residents (R17, R12, and R16) of six residents reviewed for advanced directives.

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory results were obtained and reviewed to monitor for adverse effects of anti-psychotic medications for one Resident (#4) of five residents reviewed.

Inspectors wroteBased on interview and record review, the facility failed to ensure that Medication Regimen Reviews (MRR's) and pharmacy recommendations were reviewed timely for one Resident (R18) out of five residents reviewed for MRR's. This deficient practice resulted in the potential for unnecessary medications or inappropriate durations of treatments.

Inspectors wroteThis citation pertains to intake MI00151466. Based on observation, interview and record review, the facility failed to ensure the safe administration of medications for one Resident (#10) of six reviewed, resulting in a significant error when R10 was administered another resident's medications, leading to lethargy and confusion.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Educate residents/resident representatives on the pneumonia vaccines currently available and recommended by the CDC for two residents (R10 and R72) of five residents reviewed for immunizations. 2. Administer a pneumococcal vaccination or document the clinical reasons for withholding the pneumococcal vaccination for one resident (R17) of five residents reviewed for immunizations. 3. Update vaccine consent forms and immunization policies with the pneumococcal vaccines (PCV15, PCV20 or PCV21) currently available and recommended by the Centers for Disease Control (CDC).

Inspectors wroteThis deficiency pertains to Intake MI00149589. Based on interview and record review, the facility failed to conduct regular skin assessments for one Resident (#1) of three residents reviewed for quality of care resulting in the potential for untreated skin conditions.

Inspectors wroteThis deficiency pertains to Facility Reported Incident (FRI) MI00145634. Based on observation, interview, and record review, the facility failed to prevent a serious burn injury for one Resident of 3 residents reviewed for accidents and hazards. This deficient practice resulted in a second-degree burn sustained to the upper torso of Resident #1.

Inspectors wroteThis Deficient Practice Statement (DPS) has two parts: A and B. DPS A: Based on observation, interview, and record review, the facility failed to prevent the unauthorized removal of a resident from the facility for approximately 16 hours resulting in the likelihood for serious injury, serious psychosocial harm, or death for one Resident #9 (R9) of one resident reviewed for abuse. Findings Include: The Immediate Jeopardy began on 9/18/23 at 6:07 PM when the facility failed to prevent R9's unauthorized leave from the facility by two former terminated Certified Nurse Aides (CNAs). [...]

Inspectors wroteResident #11 (R11) Review of R11's electronic medical record (EMR) revealed admission to the facility on 2/3/23 with diagnoses including chronic obstructive pulmonary disease, mild cognitive impairment, and nicotine dependence. Review of R11's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicative of moderate cognitive impairment. On 4/22/24 at 10:16 AM, an entrance conference was conducted with the Director of Nursing (DON). The DON stated there were two current smokers who resided at the facility (R11 and R21). When the DON was asked about designated smoking locations and times, she stated there are no official smoking locations but R11 and R21 preferred to smoke out by the garage or in the arbor. The DON stated there were no designated smoking times or direct staff supervision. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by failing to dispose of expired food in kitchen refrigerators. These deficient practices have the potential to result in food borne illness among any and all 23 residents of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer its policies, practices, and procedures in a manner that displayed effective and efficient use of its resources to ensure the achievement and maintenance of the highest practicable physical, mental, and psychosocial well-being for all 22 residents at the facility, as evidenced by the following: 1. The facility administration was not present during the delivery of an Immediate Jeopardy (IJ) regarding resident abuse on 4/22/24 at approximately 5:30 PM despite disclosure of the severity of the concern by state surveyors during an earlier meeting (at 2:54 PM). The IJ was delivered to the Director of Nursing (DON) who stated the Nursing Home Administrator (NHA) had already left the facility for the day (reference tag F600). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Infection Preventionist (IP) completed specialized training in infection prevention and control.

Inspectors wroteBased on interview and record review, the facility failed to assess, reassess, obtain consent, and develop care plan interventions for one Residents (R5) of twelve sampled residents for care plan revision.

Inspectors wroteR6 A review of R6's EMR revealed admission to the facility on 3/11/19 with diagnosis including: dementia with other behavioral disturbance, type 2 diabetes, major depression disorder, bipolar disorder, stage 4 chronic kidney disease, and repeated falls. A review of R6's MRR's revealed that the pharmacist made recommendations on 9/21/23, 10/24/23, 12/27/23, and 2/26/24. The facility was unable to find the pharmacists recommendation and the physician's response by the survey exit date of 4/25/24. Based on interview and record review, the facility failed to ensure monthly regimen reviews (MRR's) were completed monthly and recommendations were reviewed by a physician and follow up for five Residents (R4, R6, R20, and R21) of four residents reviewed for MRR's.

Inspectors wroteBased on interview and record review, the facility failed to ensure the provision of resident rights training requirements for three of seven employees reviewed for resident rights training.

Inspectors wroteBased on interview and record review, the facility failed to ensure the provision of infection control training for four of seven employees reviewed for infection control training.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two Residents (R15 and R20) were free from physical restraints imposed for purposes of convenience, out of twelve residents sampled for review for restraints. This deficient practice resulted in restriction of freedom of movement and the potential for injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure an unauthorized leave of absence was reported timely to the facility administrator and State Agency (SA) for one Resident (#9) of 5 residents reviewed for accident and incident reporting.

Inspectors wroteBased on interview and record review the facility failed to investigate an incident of abuse/neglect for one Resident (#9) of two residents reviewed for abuse/neglect.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident in writing with the reason for a transfer out of the facility for two Residents (R18, R20) of three residents reviewed for transfers. This deficient practice resulted in limited knowledge of the treatment plan due to lack of written transfer or discharge notification to the resident/resident's representative. R18 A review of R18's Electronic Medical Record (EMR) revealed she was transferred to the hospital on 7/7/23. There was no written notification of transfer given to R18. R18 returned to the facility on 7/10/23. A request was made for the facility's transfer policy on 4/25/24. On 4/25/24 at approximately 11:20 a.m. an interview was conducted with Registered Nurse (RN)/Director of Nursing in Training A. [...]

Inspectors wroteResident #20 (R20) A review of R20's progress notes revealed the following: 6/19/23 06:55 (6:55 AM): Late Entry: .Right hip appears swollen, non tender to touch, skin color appears normal. When resident moves right leg he grimaces and says ouch. [facility Physician's name] notified .EMS [emergency medical services] called. Resident transferred to [local hospital name] for evaluation . Review of the Clinical Census report revealed R20 was hospitalized from [DATE]. R20 returned to the facility on 6/23/23. Review of R20's EMR revealed there was no Bed Hold Authorization form completed for the 6/19/23 transfer. [...]

Inspectors wroteBased on interview and record review, the facility failed to submit a quarterly Minimal Data Set (MDS) assessment for one Resident (R15) of twelve residents sampled for timely of MDS assessments.

Inspectors wroteBased on interview and record review, the facility failed to ensure Preadmission Screening (PAS)/Annual Resident Review (ARR) Mental Illness/Intellectual Disability/Related Conditions Identification (form DCH-3878) documents were reviewed, revised, and sent to the local state agency for review and/or evaluation for one Resident (R6) of one sampled resident reviewed for PASSARs. This deficient practice resulted in the potential for residents to be excluded from receiving necessary care and services appropriate to meet their mental health needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop resident centered care plan based on the needs of one Resident (R21) of twelve sampled residents for development of resident centered care plans.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician order for one Resident (R20) and failed to obtain a physician order for an emergency medication for one Resident (R21) of twelve sampled residents reviewed for physician orders.

Inspectors wroteBased on interview and record review the facility failed to ensure the provision of trauma-informed care to mitigate triggers that may cause re-traumatization for one Resident (R6) of one resident reviewed for trauma-informed care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate assessment, measurements, and consent for bedrails was completed for one Resident (R5) of one resident reviewed for bedrails.

Inspectors wroteBased on interview and record review the facility failed to coordinate behavioral health services for one Resident (#4) of four residents reviewed for mood and behavior.

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed personnel administered medications to 1 out of 12 Residents (Resident #12) reviewed for medication administration.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate medical records for 1 of 12 residents (Resident #9) reviewed for medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed in implement enhanced barrier precautions (EBP) for one Resident (R21) of twelve sampled residents reviewed for infection control practices.

Inspectors wroteBased on interview and record review, the facility failed to ensure an eligible resident was offered influenza vaccines as recommended by the Centers for Disease Control and Prevention (CDC) for 1 of 5 residents (Resident #20) reviewed for vaccination status. Findings Include: Resident #20 (R20) Review of R20's electronic medical record (EMR) revealed initial admission to the facility on 4/4/23 with diagnoses including cerebral infarction (stroke), dementia, and aphasia (difficulty processing, using, and/or understanding language). Review of 20's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, indicative of moderate cognitive impairment. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective abuse and dementia management training program for three out of seven staff members reviewed for annual training.

Inspectors wroteIntake # M100143193 Based on interview and record review, the facility failed to protect one Resident (#1) of three residents reviewed for the right to be free from mental and/or potential sexual exploitation resulting in the potential for mental anguish and pain.