Maywood Acres Healthcare

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their policy and procedure related to grievance and complaints for one of two sampled residents (Resident 1) when there was no documentation of Resident 1's concerns and the action/resolution taken by the facility. This failure had the potential to overlook Resident 1's concerns that could result in the violation of resident rights. During a record review of Resident 1's clinical records, the admission record indicated Resident 1 was admitted on [DATE] with diagnoses that included weakness and vascular dementia (reduced blood flow to the brain and often affects person's ability to plan, organize or make decisions). Cognitive assessment indicated intact cognition, however, there are behavioral symptoms manifested by verbal aggression directed at others, refusing care that occur one to three days. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a standardized assessment and care-screening tool) accurately reflected the dialysis (medical procedure where the blood is circulated directly through a dialysis machine that uses special filters to remove waste products and excess fluid from the blood) status of one of 24 sampled residents (Resident 1). This failure had the potential for Resident 1 to not received needed services. During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was admitted on [DATE] with diagnoses that included, end stage renal disease (a condition where the kidneys have permanently lost most of their function and can no longer adequately filter waste products and excess fluid from the blood) and dependence on renal dialysis. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure when a care plan was not created for 1 of 24 sampled residents (Resident 61) with Dementia (a general term describing a group of conditions that cause a progressive decline in cognitive abilities). This failure had the potential for resident to not receive appropriate care and treatment to attain highest practicable psychosocial well-being. During a concurrent observation and interview on 8/26/25 at 2:45 p.m. with Resident 61, Resident 61 was unable to state the current year, month, or date. Resident 61 was observed in bed and stated he was waiting for a certified nursing assistant (CNA) to shave him, pointing to his face and chin. [...]

Inspectors wroteBased on observation and interview, the facility failed to write the open date on the pharmacy sticker for Resident 61's respiratory solution vials located in Medication Cart #3. This failure resulted in the potential for Resident 61 to receive a medication that had been expired or no longer effective, placing Resident 61 at risk for decreased therapeutic benefit and potential adverse health outcome.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection prevention and control practices when: 1. A nasal canula (NC) was found on the floor for one of nine residents (Resident 38). This failure had the potential for Resident 38 to acquire an infection from an unclean NC.2. Staff did not perform appropriate hand hygiene practices in the dining room during meal tray service. This failure had the potential to expose residents to cross infection contaminations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy and procedure on smoking. This failure had the potential to result in serious risk of fires and injuries for vulnerable residents with cognitive and physical impairments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure the door for one of one walk-in refrigerators in the kitchen was maintained in safe, operating condition when the door would not remain closed after being pushed shut. As a result, temperature abuse (lack of adherence to strict temperature control) could occur which could lead to food spoilage and/or growth of pathogens that placed the residents at an increased risk for foodborne illness. 2. Ensure there was an appropriate air gap between the dish machine drain and the floor sink drain to prevent contaminated water from backing up into the dish machine should a problem arise with the floor drain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the policy on checking resident room temperatures was implemented for three of nine sampled residents (Resident 45, 50 and 78). This failure placed residents at risk to have an environment were the room temperatures were not regulatred and folloiwed for a comfortable daily living .

Inspectors wroteBased on record review and interview, the facility failed to complete a CMS (Centers for Medicare & Medicaid Services) required discharged Minimum Data Set (MDS - an assessment tool and plan of care for residents in a nursing facility) assessment for one discharged resident (Resident 74). This failure resulted in an MDS discharge assessment not completed timely.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an accurate assessment, reflective of the resident's status at the time of the assessment, was done for one of five (Resident 86) sampled residents. This failure resulted in an inaccurate assessment and had the potential to result in life threatening consequences for Resident 86.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a care plan for three of three residents (Resident 49, 86 and 54) related to: 1. A pad alarm that was considered as a restraint for Residents 49 and 86 2. A diagnosis of Hepatitis C (a liver disease caused by the hepatitis C virus, which is primarily transmitted through exposure to infectious blood or body fluids that contain blood) for Resident 54. These failures had the potential for Resident 49, 86 and 54 not to receive the appropriate care and services, based on problem areas identified.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff demonstrated competency in medication administration when: 1. A licensed vocational nurse (LVN) 1 administered the wrong laxative (medication that treats constipation) to one unsampled resident (Resident 53). 2. Blood pressure and heart rate readings were not accurately documented for one of five sampled residents (Resident 68) prior to receiving the medication Carvedilol (medication to treat heart failure and high blood pressure after a heart attack). 3. Monitoring for medication side effects and bleeding complications was not implemented for one of five sampled residents (Resident 344) receiving the medication Apixaban (medication that prevents blood clots). These failures had the potential to harm these residents as a result of unsafe medication administration.

Inspectors wroteBased on interview and record review, the facility failed to ensure monitoring for side effects and manifestation of behaviors was done for Mirtazapine (a drug used to treat depression) for one Resident (Resident 54). This failure had the potential for unrecognized side effects of the Mirtazapine and occurrence of manifested of behaviors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled resident's (Resident 19, Resident 1) therapeutic mechanical soft, chopped diet order was plated correctly in the kitchen in accordance with the physician's order and facility's planned menu/diet manual. As a result, of not implementing the chopped diet safely residents were at an increased risk of choking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's lunch was served in an attractive manner when the food items on the plate were similar color (brown) and the noodles were mushy when the food was hot held for a prolonged period of time prior to the lunch meal service. Three residents expressed dissatisfaction with the facility's food during the survey(Resident 48, Resident 43, Resident 2). As a result, hot holding food for a prolonged period of time was not a method of food preparation that conserves nutritive value or appearance. In addition, food that was served lacked a variety of color creating an unappetizing appearance and could cause less food intake and weight loss.

Inspectors wroteBased on record review and interview, the facility failed to demonstrate it notified a physician of a change in condition in a timely manner and per policy and procedure, for one of two sampled residents (Resident 1). This facility failure had the potential for emergency medical care to be delayed for Resident 1.

Inspectors wroteBased on record review and interview, the facility failed to follow their policy and procedures pertaining to Residents going out on a leave of absence, for two of two sampled Residents (Resident 1 and Resident 2). This failure had the potential for the facility not to know where residents were going, while out on pass from the facility or when they returned.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the ice machine was sanitized according to manufacturer's guidelines. This failure have the potential to placed the residents at risk for gastrointestinal illnesses and other water borned illnesses.

Inspectors wroteBased on interview and record review the facility failed to ensure care services provided to residents met professional standards when: 1. Pain medications given for three residents (Resident 34, 51, and 414) were not documented as administered on the facility's Medication Administration Record ( MAR). 2. The pre (before) and post (after) pain assessments for two residents (Resident 34 and 51) were not documented on the Pain Assessment Flow Sheet (PAFS) after pain medication administration. These failures had the potential to unknowingly administer additional doses of pain medications to residents resulting to double dosing which is a medication error.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary staff had the competency and skills to keep and maintained food contact surfaces were sanitized effectively. This failure had the potential to spread food borne diseases to residents and occupants of the facility.

Inspectors wroteBased on interview and record review the facility failed to clean glucometers (machine used to measure blood sugar) per manufacturer's instructions for use. This failure had the potential to result in cross contamination and spreading of infectious disease to the residents.

Inspectors wroteBased on observation, and interview, the facility had 31 resident rooms that do not meet the required square footage of 80 square feet per resident . These rooms are: Two resident rooms: (Required 160 square footage). rooms [ROOM NUMBERS] are 148 square footage. rooms [ROOM NUMBERS] are 139 square feet. Three resident rooms with three beds occupancy: (Required 240 square footage). Rooms 3, 4, - 217 square feet. Rooms 6,7,8,9 -212 square feet. Rooms 10,11,12 -221 square feet. Rooms 14,15 -221 square feet. Rooms 16,17 -218 square feet. Rooms 20,21,22,23,24,25,26,27 -224 square feet. Rooms 28,29 -234 square feet. Rooms 30,31,32,33 -215 square feet.

Inspectors wroteBased on interview and record review the facility failed to ensure a medical physician sign the Physicians Orders for Life-Sustaining Treament (POLST) for one of 18 sampled residents (Resident 54). This failure had the potential for life sustaining orders to be not authorized or authenticated by the resident's physician which can result in the delay of medical interventions during an emergency.

Inspectors wroteBased on interview and record review the facility failed to ensure a discharge Minimum Data Set (MD- assessment data of resident ) was timely done for one resident (Resident 1) This facility failure had the potential to result in wrong entry to the federal data base .

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's careplan ( planned measures, interventions to direct care) was updated after a fall occurence for one out of 18 sampled residents (Resident 54). This failure has the potential for interventions and measures in place that won't be effective to prevent a fall recurrence .

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure consumption of therapeutic (to cure or restore to health) nutritional supplements was accurately documented and monitored in two of 18 sampled residents (Resident 6 and Resident 18). This failure had the potential to ineffectively evaluate and delay timely revision of interventions needed to meet residents' nutrition needs.

Inspectors wroteBased on interview and recored review the facility failed to ensure the use of PRN (as needed) psychotropic (medication that can affect a person's mental state) medication does not exceed 14 days for 2 out of 18 sampled residents ( Residents 23 and 60). This facility failure had the potential for unneccessary use of medication with no evaluation and assessment of need.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 18 sampled residents (Resident 13's), Foley catheter (FC) [a tube that drains urine from the bladder], was documented in the medical record. This failure resulted in inaccurate documentation that can affect the delivery of safe care and treatments.

Inspectors wroteBased on interview and record review the facility failed to provide Pneumococcal (bacterial infection) immunizations for one resident (Resident 16). This facility failure had the potential to result in Resident 16 acquiring complications from Pneumococcal disease.