Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Maple Grove Wellness & Rehabilitation during CMS and state inspections, most recent first.
Missing QAPI Plan and Performance Improvement Protocols: The facility failed to have a QAPI program in place with protocols for identifying and correcting quality deficiencies. Survey review found no personalized QAPI plan with tracking, measurement, goals, or performance thresholds; the only QAPI material provided was a single meeting sign-in sheet. The Administrator said she had no prior QAPI records, no open PIPs, and a scheduled meeting could not be held, while the Administrator, DON, and Director of Operations stated they expected a QAPI program with data collection, feedback, monitoring, analysis, and action.
Failure to Maintain an Effective QAA/QAPI Program: The facility failed to ensure its QAA/QAPI committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. The QAPI policy required quarterly committee review, monitoring of quality-related activities, and performance improvement projects, including at least one completed annually. The Administrator stated there were no open PIPs, she had no records from prior management, and a planned committee meeting could not be held. The Administrator, DON, and Director of Operations said they would expect a QAPI program with data collection, monitoring, analysis, action, and a performance improvement plan.
Unsafe and Unsanitary Resident Environment: A resident room had cove base pulling away from the wall with exposed drywall, and strong urine odors were noted in the dining area and a resident room. Several shower rooms were observed with feces and urine odors, hair and debris in drains, soiled linens and briefs, stained walls and tiles, damaged shower equipment, holes and cracks in walls, clutter, and other unsanitary items. A missing handrail was also observed near a restroom, and the resident and council reported the shower rooms were gross and cluttered.
The facility failed to complete bed rail safety assessments, review risks and benefits, and obtain informed consent before bed rail use for multiple residents. Several residents had diagnoses such as muscle weakness, fractures, obesity, cognitive impairment, or debility, and observations showed half rails, quarter rails, or mobility bars in use while records lacked side rail assessments, entrapment risk assessments, consent, and in some cases physician orders or care plan documentation.
QAPI meetings were not maintained quarterly with the required members. The facility had only one May sign-in sheet available, and the Administrator stated she had no records from prior management and that a June meeting was supposed to occur but could not. The available meeting included the Activities Director, Housekeeping, Social Services Director, Medical Director, Medical Records, MDS Coordinator, and DON, while the facility policy required a broader QAA/QAPI membership and monthly meetings.
An RN failed to clean glucometers per manufacturer directions between residents, an RN did not follow hand hygiene and glove-change practices during nephrostomy care, and an LPN and CNA handled wound care with repeated glove reuse and missed hand hygiene steps. The observations showed staff placing gloves in pockets, touching equipment and supplies with gloved hands, using the same gloves across multiple wound sites, and not keeping disinfectant wipes on glucometers for the required wet time.
Failure to obtain informed consent for psychotropic medications. Two residents and one additional resident had orders for antipsychotic, antidepressant, and/or anti-anxiety medications, but the record lacked documentation that the resident or representative was informed of the risks and benefits, treatment alternatives, or options before the medications were started. One resident had no cognitive impairment, another had cognitive impairment, and a third had severe cognitive impairment; the DON acknowledged some psychotropic consents were missing.
Failure to Attempt GDRs and Document Medication Diagnoses The facility failed to attempt GDRs for psychotropic meds for three residents and did not document appropriate diagnoses for an antipsychotic and an antidepressant for one resident. One resident with schizoaffective disorder, major depressive disorder, and bipolar disorder was receiving multiple antidepressants and an antipsychotic without GDR documentation; two other residents with schizophrenia, bipolar disorder, anxiety, depression, and paranoid schizophrenia were also receiving psychotropic meds without documented GDRs. Survey observations showed the residents in routine daily activities, and the ADM, DON, and DOP stated GDRs were expected per regulatory guidelines.
Failure to provide written transfer and bed hold notices: The facility did not document written notice to residents or their representatives when a resident was transferred to the hospital, and did not provide bed hold policy information at the time of transfer for multiple residents. Records showed repeated hospital transfers for some residents, including one resident who did not return, with no evidence of the required written notices or appeal-related transfer documentation.
Failure to complete baseline care plans within 48 hours of admission. Two residents admitted with significant diagnoses, including cancer, malnutrition, acute kidney failure, sepsis, schizophrenia, cardiomegaly, and stroke, had no documentation of a completed baseline care plan. Facility policy required a person-centered baseline care plan within 48 hours, and the DON and Administrator stated this was the expected timeframe.
Failure to Provide Scheduled Showers: Multiple residents who depended on staff for bathing/showering missed repeated scheduled showers, with shower sheets showing numerous missed opportunities and, for some residents, no documentation for an entire month. Residents with diagnoses including muscle weakness, dementia, COPD, morbid obesity, chronic respiratory failure, metabolic encephalopathy, and altered mental status reported not getting showers or not getting them often enough, and observations noted greasy hair and disheveled appearance. Interviews confirmed showers were supposed to be completed per the schedule and documented on shower sheets, but the records showed inconsistent completion and documentation.
A resident with bilateral nephrostomy tubes, bladder cancer, and urinary tract obstruction had drainage bags observed hanging around the neck or lying in a wheelchair seat, rather than kept lower than kidney level. On multiple observations, both bags were uncovered with no privacy bags in place. The resident stated that privacy bags had not been provided and that the exposed urine bags were upsetting and embarrassing; the DON and Administrator stated they would expect the bags to be covered and positioned lower than the kidneys.
Dialysis communication forms were not consistently sent with two residents on dialysis days. One resident with ESRD and hemodialysis orders had 20 missed opportunities for completed forms, and another resident with ESRD and dialysis port orders had six missed opportunities. The facility’s policy required written communication between nursing staff and the dialysis provider, but records showed the forms were only completed on some dialysis trips. The DON and Administrator stated they expected the forms to be filled out appropriately on dialysis days.
Failure to complete annual CNA performance reviews. Record review showed four of four sampled CNAs had no documentation of an annual performance review, and the facility did not provide a policy for CNA annual performance reviews. The DON stated CNA performance reviews are to be completed by the DON but were probably not being done, and the Administrator and DON said they would expect nurse aides to have a performance review every 12 months.
Missing Monthly Pharmacist Medication Regimen Reviews: The facility did not have documentation that the pharmacist completed monthly medication regimen reviews for several residents with complex psychiatric diagnoses and multiple psychotropic medications, including antidepressants, antipsychotics, and anxiolytics. The DON stated the monthly reviews were supposed to be completed but were not being done, and leadership said they expected the reviews to be completed by the pharmacist and signed by the doctor.
Facility staff did not complete required bed rail safety and maintenance checks for multiple residents with quarter rails, half rails, or grab bars in use. Records showed no maintenance assessments, and observations confirmed the rails were in place on resident beds; the DON and Maintenance Director acknowledged the safety assessments, consents, and maintenance checks had not been done.
A facility failed to keep overbed light fixtures free of stored items in multiple resident rooms. Surveyors observed pictures, hats, a necklace, a stuffed fish, an orange blanket, stuffed animals, papers, and other items placed on the lights, and the Administrator, DON, and Director of Operations stated they would expect the lights to be free from objects.
Failure to provide required CNA training was identified for three of three sampled CNAs. Records showed missing or incomplete in-service documentation, including no documented training in dementia care/management, abuse prevention, neglect, special needs of residents, or care for cognitively impaired residents. The Lead CNA/Staffing Coordinator reported frequent in-services on topics such as handwashing, bedside manners, patient care, and lift use, while the Administrator and DON stated they expected at least 12 hours of annual in-services including the required topics.
Survey Results Not Readily Accessible: The facility failed to keep survey results in a readily accessible area for residents, family members, and legal representatives to review without asking. Observations showed no posted survey results, residents reported the binder had been removed from the lobby area, the SS Director was unaware of its location, and Receptionist A later found the survey results on a desk with other binders. The Administrator, DON, and Director of Operations stated they would expect the results to be available for review without asking.
A nurse failed to verify a resident's identity and administered another resident's morphine sulfate and lorazepam, resulting in the resident experiencing adverse symptoms and requiring Narcan and hospital transfer. The nurse did not follow the facility's medication administration policy, including the required identity checks and communication with the resident.
Nineteen residents did not receive prescribed medications or treatments when an LPN refused to cover a hallway after another nurse left early, and the DON was unable to secure agency coverage in time. Residents with conditions such as diabetes, hypothyroidism, and heart disease missed critical care, and staff attempts to notify the DON during the shift were unsuccessful.
Facility staff did not notify the physician of a resident's urine culture and sensitivity results, which showed E. coli resistant to the prescribed antibiotic Bactrim DS. The resident, with multiple chronic conditions, was treated for cellulitis, but the required communication of lab results to the physician did not occur, as the Infection Preventionist failed to follow protocol.
The facility failed to provide the required minimum of two showers per week for five residents, leading to complaints and observations of poor hygiene. Residents with various medical conditions requiring assistance for bathing reported infrequent showers and unkempt appearances. The facility's policy was not followed, and the administrator acknowledged the expectation for regular showers.
The facility failed to repair essential kitchen equipment and ensure proper food storage in residents' personal refrigerators. Observations revealed malfunctioning kitchen appliances and expired, improperly stored food items. Interviews indicated a lack of clear responsibility and process for maintaining the refrigerators, leading to potential health risks for residents.
The facility failed to develop a Quality Assurance and Performance Improvement Plan (QAPI). Despite having policies outlining the QAPI process, the facility did not have a QAPI plan in place. The Administrator admitted they are starting fresh with QAPI and could not find any past documentation, with no Performance Improvement Projects (PIPs) in place.
The facility failed to ensure the QAPI committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. Key personnel did not attend the QAPI meeting, and no Performance Improvement Projects (PIPs) were in place. The Administrator admitted to starting fresh with QAPI and lacking past documentation, indicating a failure to address systemic quality deficiencies.
The facility failed to hold quarterly QAPI meetings with the required members, as mandated by their policy. A review showed no evidence of key members attending a recent meeting, and the Administrator admitted to not finding documentation of past meetings or having any PIPs in place. The facility census was 92 residents.
The facility failed to notify residents and/or their representatives in writing of transfers or discharges to a hospital, including the reasons for the transfer, and did not notify the Office of the State Long-Term Care Ombudsman. This deficiency was identified for 10 residents out of a sample of 19, with the facility's census being 92.
The facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, affecting all residents. Nursing schedules from February to April 2024 showed 11 days without RN coverage. The Administrator acknowledged the expectation for RN coverage, and the facility lacked an RN coverage policy.
The facility failed to notify residents of the availability and location of the most recent survey results. Multiple residents were unaware of a binder containing survey results, and the Administrator admitted the results had been misplaced following an administration change. A new survey binder was eventually created and placed on the front table.
The facility failed to consistently document the code status for two residents, leading to discrepancies in their medical records. Interviews with staff revealed confusion about the methods for determining code status, resulting in conflicting information being recorded.
The facility failed to provide a safe, clean, comfortable, and homelike environment. Observations revealed debris on a resident's oxygen concentrator, unpainted drywall patches, stained privacy curtains, and missing closet drawers. The Administrator and Director of Operations acknowledged these issues, indicating a deficiency in maintaining the expected standards.
The facility failed to provide adequate discharge documentation for a resident transferred to another facility, including a discharge summary and recapitulation of the resident's stay. Interviews with staff revealed a misunderstanding of the discharge policy, leading to the omission of required documentation.
The facility failed to inform residents and/or their legal representatives in writing of the bed hold policy at the time of transfer to the hospital for ten residents. Despite the facility's policy requiring written notification, the Social Services Director admitted that this was not done, and the Administrator and Director of Operations expected staff to provide this information, highlighting a discrepancy between policy and practice.
The facility failed to complete significant change MDS assessments within the required 14-day timeframe for two residents following their discharge from hospice services. The Administrator, Director of Operations, and MDS Coordinator acknowledged the oversight, which did not comply with the RAI Manual requirements.
The facility failed to document accurate MDS assessments for five residents, leading to discrepancies in their medical records. Errors included incorrect indications of insulin use, inaccurate diagnoses, and omissions of several medical conditions. Interviews with staff confirmed these inaccuracies, highlighting a failure to adhere to the facility's MDS completion and submission guidelines.
The facility failed to update and revise care plans for two residents, omitting critical interventions such as PICC line management. This deficiency was acknowledged by the Administrator and Director of Operations, who stated that care plans should reflect the current condition of the residents.
The facility failed to follow physician's orders for two residents and did not obtain a treatment order for one resident. One resident had inconsistent administration times for levothyroxine and was observed wearing prevalon boots without an order. Another resident also had inconsistent levothyroxine administration times, leading to abnormal TSH levels.
The facility failed to follow professional standards for PICC line care for two residents. One resident's PICC line dressing was not changed weekly, and the infusion was not disconnected or flushed promptly. Another resident's PICC line dressing was not changed weekly, and the line was accidentally pulled out during a dressing change, requiring replacement. The facility did not adhere to physician orders and professional standards for PICC line care.
The facility failed to screen four residents for Tuberculosis (TB) as per their policy. Medical records showed lapses in compliance, with missing documentation for annual TB tests and screenings. The facility's census was 92, indicating potential broader non-compliance issues.
The facility failed to provide a dining room large enough to accommodate all residents, leading to overcrowding and discomfort. Observations showed insufficient seating, and residents reported having to take food back to their rooms or wait for a seat. The Director of Operations acknowledged the issue but did not provide a satisfactory solution.
The facility failed to maintain a safe environment by allowing items to be stored on overbed light fixtures in multiple rooms. Observations included stuffed animals and crafts placed on the lights, posing a potential fire hazard. The facility did not have a specific policy for overbed lighting safety, although the admission packet prohibited such practices.
The facility failed to provide at least twelve hours of annual in-service education for two CNAs, with one CNA receiving only one hour and another receiving four hours of training. The Administrator confirmed the expectation of twelve hours of training per year, and the facility lacked an in-service training policy.
The facility staff failed to post the required daily nurse staffing information in a prominent location readily accessible to residents and visitors. Observations showed the information was not visible near nurse's stations or the main lobby. A CNA confirmed it was posted in the nurse's office, making it inaccessible to residents or visitors. The Administrator expected the information to be posted in a prominent location.
Missing QAPI Plan and Performance Improvement Protocols
Penalty
Summary
The facility failed to have a QAPI program in place with protocols describing how it would identify and correct quality deficiencies. Based on interview and record review, the surveyor found that the facility did not have a personalized QAPI plan containing the necessary protocols for tracking and measuring performance or establishing goals and thresholds for performance measurement. The facility census was 86, and the deficient practice had the potential to affect all residents in the facility. Review of the facility's QAPI Program policy, revised 10/24/22, showed that the facility was expected to maintain an ongoing, facility-wide QAPI program, develop and implement a written QAPI plan, and use feedback, monitoring, analysis, and action to identify and resolve quality deficiencies. However, the only QAPI material provided was a QAPI meeting sign-in sheet dated May with no year, and the Administrator stated she only had that sign-in sheet and nothing from prior management or administration. She also stated there were no open PIPs and that a meeting scheduled for June could not be held. During a later interview, the Administrator, DON, and Director of Operations said they expected the facility to have a QAPI program that included data collection, feedback, monitoring, analysis, and action, and to develop a performance improvement plan based on those results.
Failure to Maintain an Effective QAA/QAPI Program
Penalty
Summary
The facility failed to ensure the QAA/QAPI committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. The report states that the facility’s QAPI policy, revised 10/24/22, required the QAA Committee to identify and correct quality deficiencies, meet at least quarterly to review reports and monitor quality-related activities, oversee and authorize QAPI activities, and conduct distinct performance improvement projects, including at least one completed annually. During interviews, the Administrator stated on 08/29/25 that she did not have anything from the prior management/administration, that there were no PIPs open, and that a meeting that was supposed to occur in June could not be held. On 08/26/25, the Administrator, DON, and Director of Operations stated they would expect the facility to have a QAPI program in place that included data collection, feedback, monitoring, analysis, and action, and to develop a performance improvement plan based on those results.
Unsafe and Unsanitary Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for Resident #52 and other residents. Observation of a resident room showed two sections of cove base pulling away from the wall, exposing unfinished drywall. The facility also had a strong urine odor in the small dining room and in Resident #52’s room during separate observations. Multiple shower rooms were observed in poor condition and with strong odors. Shower Room One had a strong feces and urine odor, debris and loose hair around the floor drain, a soiled wipe on the floor, a soiled brief on the bottom of a sit-to-stand lift, hospital gowns over a lidded container, and hospital ID bracelets on a storage container. Shower Room Two had a strong musty urine odor, a drain full of hair and debris, a wet washcloth on the floor, a toilet containing yellow liquid, stained disposable underwear draped over a trash can, orange-red stains on shower tiles and part of the wall, a shower chair placed on top of a ripped foam shower mattress, gloves under a sign, a shoe and foot brace in the corner, and two holes in the wall. Shower Room Three had a strong musty urine odor, towels on a bath chair and on the floor, open bottles of baby oil and perfume, a broken pretzel on the floor, a hospital gown and used face mask on a shelf, a missing piece of floor tile trim, and a crack in the shower wall. Shower Room Four had a musty odor, an out-of-order sign, a toilet with yellow liquid, no toilet paper on the holder, utensils beside body wash, and a brief and paper towels on a storage container. A three-foot missing handrail was also observed near the restroom across from the large dining room. Resident #52 stated the shower rooms were gross and very cluttered and that one shower had hardly any water coming out. Residents in council said the shower rooms needed to be cleaned, not just mopped. The Administrator, DON, and Director of Operations stated they would expect shower rooms to be free from garbage, hair, pests, and for floors, toilets, and walls to be clean, sanitary, and in good repair.
Failure to assess and obtain consent for bed rail use
Penalty
Summary
The facility failed to assess residents for the risk of entrapment and failed to review the risks and benefits of bed rails before installation or use. It also failed to obtain informed consent from residents and/or their representatives for bed rail use for five sampled residents and three additional residents outside the sample. The facility’s bed rail policy required individual assessment, evaluation of alternatives, entrapment risk assessment, consent when bed rails were used as enablers, care plan updates, quarterly interdisciplinary review, and maintenance checks of bed dimensions and rail installation. Resident #1 had diagnoses including muscle weakness, need for assistance with personal care, and spastic hemiplegia affecting the left side. The record contained no documentation of a side rail assessment, entrapment risk assessment, informed consent, or physician order for side rails. The care plan noted substantial assistance needs and later changed a half side rail to a mobility bar on the left side. On observation, the resident’s bed had a U-shaped grab bar on the left side. Resident #2 had diagnoses including a left femur fracture, muscle weakness, chronic pain, morbid obesity, and need for assistance with personal care. The record contained no documentation of a side rail assessment, informed consent, or physician order, although the care plan listed bilateral side rails for bed mobility. On observation, quarter rails were present on both sides of the bed, and the resident stated the left rail was used to help reposition due to the broken leg and being bedbound. Similar documentation gaps were found for Residents #10, #18, #34, #64, #72, and #81, with observations showing half rails or quarter rails raised on beds while records lacked side rail assessments, entrapment risk assessments, informed consent, and, for several residents, physician orders or care plan references to side rail use.
QAPI Committee Did Not Meet Quarterly With Required Members
Penalty
Summary
The facility failed to maintain quarterly Quality Assurance & Performance Improvement (QAPI) meetings with the required members. The facility census was 86. Review of the facility’s Quality Assessment and Assurance (QAA) Committee policy, revised 06/20, showed that the QAA Committee was to include the Director of Nursing Services, at least one physician, the Pharmacist Consultant, the Director of Activities, the Infection Control Coordinator, the Director of Dietetic Services, the Director of Medical Records, the Director of Rehabilitation Services, and directors of other departments as necessary, and that the committee was to meet monthly and keep minutes documenting required meeting information. Review of the QAPI Quarterly Meeting sign-in sheet, dated May and provided by the Administrator, showed attendance by the Activities Director, Housekeeping, Social Services Director, Medical Director, Medical Records, MDS Coordinator, and Director of Nursing. During interview, the Administrator stated that the May sign-in sheet was all she had for QAPI and that she did not have anything from the prior management/administration. She also stated they were supposed to have a meeting in June but could not. The Administrator, DON, and Director of Operations later stated they would expect a QAPI meeting to be held at least quarterly with the minimum required members.
Infection Control Failures During Glucose Monitoring, Nephrostomy Care, and Wound Care
Penalty
Summary
The facility failed to maintain infection control practices during nephrostomy tube care for one resident, failed to perform proper hand hygiene during wound care for one resident, and failed to sanitize glucometers per manufacturer directions between residents for four residents. The report also cites the facility’s policies for blood glucose monitoring, hand hygiene, and catheter care, along with the manufacturer’s instructions for Super Sani-Cloth use, which required the treated surface to remain wet for two minutes. During fingerstick blood sugar testing for four residents, an RN obtained a glucometer, lancet, and alcohol wipe, performed the blood glucose check, then removed gown and gloves, exited the room, sanitized hands, donned gloves, and wiped the glucometer with a Super Sani cloth for about ten seconds before placing it on a paper towel inside the nurse cart. The glucometer was not kept wet for the two-minute kill time required by the manufacturer. When interviewed, the RN stated he/she only wiped off the glucometers, did not know they had to be wrapped, and did not know the required wet time or kill time for the wipes. During nephrostomy care for one resident, an RN sanitized hands, gathered supplies, donned PPE, and entered the room, but touched the wheelchair handles while wearing the same gloves and later removed dressings from both sides without changing gloves between sides. The RN left the room to get tape, removed PPE, did not sanitize hands, then returned and continued care. The RN used the same gloves while cleansing both sides of the nephrostomy site and down the tubing, then taped both drainage sponges in place. The RN later stated that both sides were considered dirty, but acknowledged that changing gloves between the right and left sides made sense to prevent cross contamination. During wound care for two residents, an LPN and CNA placed gloves in their pockets and used them during treatment. For one resident, the LPN removed a dressing from the right forearm, removed gloves, and donned new gloves without hand hygiene before removing abdominal dressings and later the heel and buttocks dressings. The LPN used the same gloves while cleansing multiple abdominal wounds, retrieved scissors from a pocket, and handled supplies and dressings throughout the procedure. For another resident, the LPN removed a dressing from the right forearm, then removed abdominal dressings and opened supplies without hand hygiene, used the same gloves while cleansing three abdominal wounds, and later changed gloves multiple times without hand hygiene while treating the heel and buttocks wounds. The CNA handled gloves and supplies with gloved hands, emptied the resident’s urinal, and assisted during the procedure. The LPN stated he/she had not been told to wash or sanitize with glove changes.
Failure to Obtain Psychotropic Medication Informed Consent
Penalty
Summary
The facility failed to ensure that residents with orders for psychotropic medications were informed by the physician or other practitioner of the risks and benefits of the proposed care, treatment alternatives, and the option to choose the preferred alternative before psychotropic medications were started. For Resident #1, the record showed diagnoses including schizoaffective disorder, major depressive disorder, and bipolar disorder, along with orders for amitriptyline, Cymbalta, trazodone, and Vraylar, but there was no documentation that the resident or representative was informed of the risks and benefits prior to initiation of these psychotropic medications. The quarterly MDS showed no cognitive impairment and documented use of antipsychotic and antidepressant medications in the seven-day lookback period. For Resident #5, the record showed diagnoses including dementia, cognitive communication deficit, schizophrenia, major depressive disorder, and anxiety disorder, with an order for quetiapine and monitoring for antipsychotic side effects, but there was no documentation that the resident or representative was informed of the risks and benefits before the psychotropic medication was initiated. For Resident #11, the record showed diagnoses of paranoid schizophrenia, major depressive disorder, and anxiety disorder, with orders for lorazepam, Seroquel, and sertraline, along with monitoring orders for antidepressant, anti-anxiety, and antipsychotic side effects, but there was no documentation that the resident or representative was informed of the risks and benefits prior to initiating psychotropic medications. The quarterly MDS for Resident #11 showed severe cognitive impairment and use of antipsychotic, anti-anxiety, and antidepressant medications in the seven-day lookback period. The DON stated that psychotropic medication consents should be completed and acknowledged that some were missing, and the Administrator, DON, and Director of Operations stated they would expect psychotropic consents to be completed for residents taking psychotropic medications.
Failure to Attempt GDRs and Document Appropriate Diagnoses for Psychotropic Medications
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) for psychotropic medications for three sampled residents and failed to provide an appropriate diagnosis for the use of an antipsychotic and an antidepressant for one resident. The report states that Resident #1 had diagnoses of schizoaffective disorder, major depressive disorder, and bipolar disorder, and was receiving amitriptyline for depression, Cymbalta related to cerebral infarction, trazodone for insomnia, and Vraylar related to acute upper respiratory infection, with no documentation of any attempted GDRs and no documentation that the consultant pharmacist or physician addressed the need for appropriate diagnoses for Cymbalta and Vraylar. Resident #9 had diagnoses of schizophrenia, bipolar II, anxiety, major depressive disorder, and borderline personality disorder, and was receiving Cymbalta for bipolar II disorder and anxiety, Risperdal for schizophrenia, and Cymbalta for depression, with no documentation of any attempted GDRs. Resident #11 had diagnoses of paranoid schizophrenia, major depressive disorder, and anxiety disorder, and was receiving lorazepam for anxiety, Seroquel for schizophrenia, and sertraline for depression, with no documentation of any attempted GDRs. Observations during the survey showed Resident #1 seated in a wheelchair wearing a smoking apron and ready to go to therapy, Resident #9 sitting upright in bed getting ready for lunch, and Resident #11 seated in a wheelchair near the smoking door visiting with his sister. During interview, the Administrator, DON, and Director of Operations stated they would expect GDRs to be completed per regulatory guidelines.
Failure to Provide Written Transfer and Bed Hold Notices
Penalty
Summary
The facility failed to notify residents and/or their representatives in writing of transfers or discharges to a hospital and failed to provide written information about the bed hold policy at the time of hospital transfer for three sampled residents and one additional resident outside the sample. The facility’s Bed Hold policy stated that residents or their personal representatives are to be advised in writing upon admission and notified in writing any time the resident is transferred to a general acute care hospital, and the Transfer and Discharge policy required written notice of transfer/discharge and related appeal information, with a copy placed in the medical record. Resident #1 was transferred to the hospital twice and readmitted both times, with no documentation that written transfer notification was provided. Resident #9 was transferred to the hospital twice and returned to the facility, with no documentation that written transfer notification or the bed hold policy was provided. Resident #75 was transferred to the hospital once and returned, with no documentation of written transfer notification or the bed hold policy. Resident #94 was transferred to the hospital and did not return, with no documentation that written transfer notification or the bed hold policy was provided. During interview, the Administrator, DON, and Director of Operations stated they would expect residents or families to be notified in writing of transfers and bed hold forms to be completed per regulation.
Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for two residents, Resident #94 and Resident #96, and there was no documentation that either resident had a completed baseline care plan. Resident #94 was admitted with diagnoses including cognitive communication deficit, breast cancer, severe protein calorie malnutrition, acute kidney failure, and localized edema. Resident #96 was admitted with diagnoses including sepsis due to methicillin-susceptible staphylococcus aureus, non-Hodgkin's lymphoma, schizophrenia, cardiomegaly, and stroke. The facility policy titled Care Planning stated that a licensed nurse would initiate the care plan and that the facility would develop a person-centered baseline care plan for each resident within 48 hours of admission. During interview, the DON stated nursing should start the baseline care plan, social services should complete a portion, and medical records should lock it, and that it should be completed within 48 hours of admission. The Administrator, DON, and Director of Operations also stated they would expect baseline cares to be completed within 48 hours of admission.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide showers for multiple residents who were dependent on staff for bathing or showering. Resident #1 had diagnoses including muscle weakness, need for assistance with personal care, and spastic hemiplegia of the left non-dominant side, and his/her MDS showed dependence on staff for showering. The resident was scheduled for showers twice weekly, but shower sheets showed 14 missed shower opportunities out of 26, including no shower sheets for June and multiple missed opportunities in July. During interview, the resident stated he/she was not getting showers. Resident #5 had diagnoses including muscle weakness, dementia, and COPD, and the MDS showed cognitive impairment and that showering/bathing was not attempted due to medical condition or safety. Although scheduled for showers twice weekly, shower sheets showed 12 missed opportunities out of 25. Resident #34 had diagnoses including morbid obesity, muscle weakness, and need for assistance with personal care, and the MDS showed dependence on staff for showering. Shower sheets showed 14 missed opportunities out of 26, and the resident stated he/she was not getting showers the way he/she should, reporting that he/she was only getting a shower once a week if that and sometimes not even that often. Resident #60 had diagnoses including chronic respiratory failure, cognitive communication deficit, need for assistance with personal care, COPD with acute exacerbation, and altered mental status, and the MDS showed substantial/maximum assistance needed for showering/bathing. Shower sheets showed 16 missed opportunities out of 26, including no shower sheets for June. Resident #81 had diagnoses including metabolic encephalopathy, cognitive communication deficit, need for assistance with personal care, morbid severe obesity, and altered mental status, and the MDS showed dependence on staff for bathing. Shower sheets showed 17 missed opportunities out of 26, including no shower sheets for June. Interviews with the Lead CNA/Staffing Coordinator and the Administrator, DON, and Director of Operations indicated showers were expected to be completed per the shower schedule, with shower sheets completed, signed, dated, and refusals documented, but the records showed repeated missed showers and inconsistent documentation.
Nephrostomy Drainage Bags Left Exposed and Positioned Improperly
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with bilateral nephrostomy tubes. The resident had diagnoses including bladder cancer, artificial openings to the urinary tract, hydronephrosis with renal and ureteral calculus obstruction, and obstructive and reflux uropathy. The resident’s care plan identified bilateral nephrostomy tubes, noted that the resident had behaviors, and documented that the resident had been educated that the nephrostomy tubes needed to be lower than the kidneys for proper drainage, but the resident continued to wear them around the neck. The facility’s policy for catheter care stated that collection bags should be kept below the level of the bladder and that the resident’s privacy and dignity would be protected by placing a cover over the drainage bag when the resident was out of bed. The facility did not provide a policy regarding nephrostomy tube care. Observation showed the resident’s bilateral nephrostomy drainage bags at times laying in the wheelchair seat and at other times hanging around the resident’s neck from a white stretchy band. On multiple observations, the bags were exposed with no privacy bags covering either drainage bag. During interview, the resident stated that no privacy bags had been provided since returning from the hospital and that it was upsetting and embarrassing to have urine bags hanging from the neck where others could see them. The resident also stated that privacy bags had still not been provided despite requests. The Administrator and DON stated that they would expect nephrostomy tube collection bags to be covered with privacy/dignity bags and positioned lower than the kidneys.
Dialysis Communication Forms Not Sent With Residents
Penalty
Summary
The facility failed to ensure that communication forms reflecting ongoing coordination and collaboration between facility staff and dialysis staff were sent with two residents on all dialysis days. The facility’s Dialysis Care Policy required nursing staff to communicate pertinent information in writing to the dialysis staff and to use a Nurse Dialysis Communication Record or comparable form in the electronic medical record to convey information to the dialysis provider. Survey review found that this process was not consistently followed for Resident #20 and Resident #48. Resident #20 had diagnoses including ESRD, dependence on renal dialysis, and adult failure to thrive, with orders for hemodialysis on Monday, Wednesday, and Friday and for assessment of the fistula and shunt site each shift. Review of dialysis communication forms showed only seven completed forms between 05/01/25 and 08/28/25, with 20 missed opportunities when the resident attended dialysis 27 times. Resident #48 had ESRD, dependence on renal dialysis, renovascular hypertension, and intestinal malabsorption, with orders for dialysis three times weekly and assessment of the right chest port for infection or bleeding. Review of dialysis communication forms showed seven completed forms between 07/30/25 and 08/27/25, with six missed opportunities. During interview, Resident #48 stated the facility packed lunch, took vital signs, weight, and any needed blood sugar checks or medications, and the resident brought the communication form back to the facility for the charge nurse. The DON stated several nurses had recently been terminated because they had not been doing things correctly, and the Administrator, DON, and Director of Operations stated they would expect residents to have a communication form appropriately filled out on dialysis days.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that four of four sampled CNAs received an annual performance review. Record review showed CNA F, hired 09/19/24, had no documentation of an annual performance review; CNA G, hired 07/16/24, had no documentation of an annual performance review; CNA N, hired 07/01/24, had no documentation of an annual performance review; and CNA O, hired 07/01/24, had no documentation of an annual performance review. The facility also did not provide a policy for CNA annual performance reviews. During interviews, the DON stated CNA performance reviews are to be completed by the DON but were probably not being done, and the Administrator and DON stated they would expect nurse aides to have a performance review completed every 12 months.
Missing Monthly Pharmacist Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that medication usage was evaluated on an ongoing basis by not providing documentation of monthly medication regimen reviews completed by the pharmacist for three residents in the sample and one resident outside the sample. The facility policy titled Documentation and Communication of Consultant Pharmacist Recommendations stated that the consultant pharmacist's observations and recommendations should be communicated and that the date each medication regimen review is completed should be documented in the medical record or other designated manner. Resident #1 had diagnoses including schizoaffective disorder, major depressive disorder, and bipolar disorder, and had orders for amitriptyline, Cymbalta, trazodone, and Vraylar, but there was no documentation of monthly pharmacist medication regimen reviews. Resident #5 had diagnoses including dementia, cognitive communication deficit, schizophrenia, major depressive disorder, and anxiety disorder, and had an order for quetiapine, but no documentation of monthly pharmacist reviews was found. Resident #9 had diagnoses including schizophrenia, bipolar II, anxiety, major depressive disorder, and borderline personality disorder, with orders for Cymbalta and Risperdal, and Resident #11 had diagnoses including paranoid schizophrenia, major depressive disorder, and anxiety disorder, with orders for lorazepam, Seroquel, and sertraline; neither record contained documentation of monthly pharmacist medication regimen reviews. During interviews, the DON stated the pharmacist should be completing medication reviews each month but they were not being completed, and the Administrator, DON, and Director of Operations stated they would expect monthly medication reviews to be completed by the pharmacist and signed by the doctor.
Failure to Inspect Bed Rails and Related Equipment
Penalty
Summary
Facility staff failed to conduct regular inspections of bed frames, mattresses, and side rails as part of a maintenance program for five sampled residents and three additional residents outside the sample. The facility’s Bed Rail policy stated that bed rails should be individually assessed, reviewed at least quarterly, and checked by Maintenance or designee for proper installation and bed dimensions, but the record review showed no documentation of maintenance assessments for Residents #1, #2, #10, #18, #34, #64, #72, and #81. Observations showed multiple residents with bed rails in use, including U-shaped grab bars, quarter rails, and half rails in raised or upright positions on both sides of the bed. One resident said the left rail was used to help reposition due to a broken leg and being bedbound, and another resident said the rails were used to pull to one side but could not fully turn or move in bed without staff assistance. During interviews, the DON stated the facility had not been doing the safety assessments, bed rail consents, or maintenance checks, and the Maintenance Director said he was not aware the assessments were needed for bedrails.
Objects Stored on Overbed Light Fixtures
Penalty
Summary
The facility failed to provide a safe and functional environment for residents by allowing items to be stored on top of overbed light fixtures in seven resident rooms. During observations, surveyors found a picture on an overbed light in one room, two ball caps on an overbed light in another room, a stuffed fish and an orange blanket folded on an overbed light in a third room, several hats across an overbed light in another room, a picture on an overbed light and a necklace on an overbed light in one room, and in another room stuffed animals, papers, popsicle stick art, various other items, a framed photo, and canvas art placed on overbed light fixtures. The facility did not provide a policy regarding storing objects on resident light fixtures. During interview, the Administrator, DON, and Director of Operations stated they would expect lights to be free from objects.
Failure to Provide Required CNA Training
Penalty
Summary
The facility failed to provide the required trainings for three of three sampled CNAs, with no policy provided regarding the required annual nurse aide training requirements. Review of CNA F’s in-service record showed a hire date of 11/25/24 and no documented hours of in-services from 11/25/24 through 08/15/25, with no documented training on dementia care/management, abuse prevention, neglect, areas of weakness that might need extra training, special needs of residents, or training for cognitively impaired residents. CNA G’s record showed a hire date of 07/16/24 and 51 in-services dated from 09/20/24 through 08/15/25, but no documented training on dementia care/management, special needs of residents, or training for cognitively impaired residents. CNA N’s record showed a hire date of 07/01/24 and 46 in-services dated from 09/20/24 through 08/15/25, but no documented training on dementia care/management, special needs of residents, or training for cognitively impaired residents. During interview, the Lead CNA/Staffing Coordinator said there were multiple in-services a week, usually three per week, including handwashing, bedside manners, patient care, and lift use, and that they reeducate often. The Administrator and DON said they would expect nurse aides to have at least 12 hours of in-services a year and for the in-services to include the required trainings.
Survey Results Not Readily Accessible
Penalty
Summary
The facility failed to keep survey results in a readily accessible area where residents, family members, and legal representatives could review them without asking. The facility policy stated that the most recent survey results were to be posted in a place readily accessible to residents, family members, and legal representatives, and that a notice of availability of survey reports would be posted in a prominent and accessible area. However, observations on 08/26/25 at 10:15 A.M., 08/27/25 at 8:40 A.M., and 08/28/25 at 11:05 A.M. showed no posted survey results available. During a resident council meeting on 08/28/25 at 11:00 A.M., residents said there had been a survey result binder near the front offices in the lobby, but it was no longer there. In an interview on 08/28/25 at 11:09 A.M., the Social Services Director said the survey binder had been on a table in the front lobby but was no longer aware of its location. At 11:10 A.M., Receptionist A found the survey results on his/her desk with various other binders. On 08/29/25 at 7:30 P.M., the Administrator, DON, and Director of Operations said they would expect survey results to be available for residents and families to read without asking.
Failure to Prevent Significant Medication Error Due to Improper Resident Identification
Penalty
Summary
A significant medication error occurred when a nurse administered another resident's prescribed medications—morphine sulfate and lorazepam oral concentrate—to a cognitively intact resident with multiple chronic conditions, including diabetes, chronic kidney disease, heart failure, COPD, chronic respiratory failure, and chronic pancreatitis. The nurse failed to verify the resident's identity, did not explain the medications being administered, and did not confirm the resident's name prior to administration. The nurse was running behind on the medication pass and, in haste, called out the intended recipient's name, to which the wrong resident responded, and then administered the medications without further verification. Shortly after receiving the incorrect medications, the resident experienced nausea and a rapid decline in condition, including changes in vital signs and mentation. The resident reported that the nurse did not communicate or identify herself, nor did she provide any information about the medications being given. The error was discovered when the resident questioned what had been administered and another nurse intervened to monitor the resident's condition. The facility's medication administration policy required verification of resident identity and adherence to the seven rights of medication administration, including the right resident, right medication, and right dose. The nurse involved admitted to not following these protocols due to being in a hurry. The incident resulted in the resident requiring administration of Narcan and transfer to the hospital for further evaluation.
Failure to Administer Medications and Treatments Due to Staffing Refusal
Penalty
Summary
The facility failed to follow physician's orders for 19 residents on the 100 hall, resulting in missed administration of critical medications and treatments. The review of medical records and medication administration records revealed that residents with diagnoses such as Type II Diabetes Mellitus, Hypothyroidism, Coronary Heart Disease, pneumonia, COPD, and Muscular Dystrophy did not receive prescribed medications, including various types of insulin, Levothyroxine, antibiotics, pain medication, and inhalation treatments. Blood sugar checks and other ordered care were also not performed as required by the residents' care plans and physician orders. The deficiency occurred during the night shift when only one nurse, an LPN, remained after the scheduled nurse for the 200 hallway left early. The LPN assigned to the 100 hallway refused to provide care or administer medications to the residents on that hall, stating discomfort with covering both hallways due to limited experience at the facility. The Director of Nursing (DON) was informed of the staffing issue and attempted to secure an agency nurse, who was expected to arrive by 11:00 P.M., but did not arrive until the morning. The DON left the facility after giving the keys to the LPN, who refused to accept responsibility for the 100 hallway. Throughout the night, no medications or treatments were administered to any residents on the 100 hallway. Staff, including a CNA, attempted to contact the DON to report the ongoing issue, but did not receive a response until after the shift. The following morning, the LPN confirmed to the DON that no care had been provided to the 100 hallway residents, and subsequently resigned. The facility did not provide a policy on medication administration when requested.
Failure to Notify Physician of Antibiotic-Resistant UTI Lab Results
Penalty
Summary
Facility staff failed to ensure proper antibiotic stewardship for a resident when they did not notify the resident's physician of the results from a urine culture and sensitivity (C&S) test. The resident, who had a history of diabetes, chronic kidney disease stage 2, COPD, hypertension, and adult failure to thrive, complained of burning during urination and had a urine sample collected. The physician was contacted for other symptoms and prescribed Bactrim DS for cellulitis, but there was no documentation that the physician was informed of the urine C&S results, which later showed Escherichia coli resistant to Bactrim DS. The facility's policy required staff to communicate pertinent clinical information, including lab results, to physicians to promote appropriate diagnosis and antibiotic prescribing. However, the Infection Preventionist, who was responsible for reviewing lab results and notifying the physician, did not follow this protocol. The Director of Nursing confirmed that the physician was not made aware of the urine C&S results, and the physician stated that a different antibiotic would have been prescribed if notified. There was no documentation that the alternate physician reviewed the lab results during a subsequent visit.
Failure to Provide Adequate Showering for Residents
Penalty
Summary
The facility failed to provide a minimum of two showers per week for five out of six sampled residents, potentially affecting all residents in the facility with a census of 92. The facility's policy stated that residents should be offered a shower at least once weekly and as requested, but this was not adhered to. The Resident Council Meeting Minutes also indicated ongoing complaints about the lack of showers. Resident #1, with diagnoses including supra ventricular tachycardia, respiratory failure, and depression, was observed with body odor and unkempt hair. The resident reported receiving showers only once or twice a month, despite needing assistance from staff. Resident #2, with severe cognitive impairment and multiple health issues, also reported not receiving the required showers, leading to greasy hair and dirty sheets. Both residents expressed dissatisfaction with the frequency of showers and the lack of staff assistance. Similarly, Residents #4, #5, and #6, all with various medical conditions requiring assistance for bathing, reported receiving showers far less frequently than the expected twice a week. Observations confirmed their unkempt appearance and body odor. Interviews with these residents revealed that they often requested showers but were either ignored or given excuses by the staff. The facility administrator acknowledged the expectation for showers to be given at least twice a week and for refusals to be documented.
Facility Fails to Maintain Kitchen Equipment and Ensure Proper Food Storage
Penalty
Summary
The facility failed to repair essential kitchen equipment, including the convection oven, stove top burners, flat top grill, and oven. Observations revealed significant issues such as a wooden block holding up the stove, rust covering the inside of the oven, missing knobs, and debris buildup. Interviews with the Dietary Manager and cooks confirmed that the malfunctioning equipment slowed down meal preparation and made it challenging to cook meals efficiently. Despite informing the administration, the necessary repairs or replacements were not made, affecting the dietary staff's ability to perform their duties effectively. The facility also failed to ensure that food stored in residents' personal refrigerators was maintained at safe temperatures and that expired foods were discarded. Observations of several residents' refrigerators showed expired and improperly stored food items, including undated leftovers and uncovered containers. Interviews with residents indicated that no one regularly checked their refrigerators for expired food, temperature, or cleanliness. The Dietary Manager, housekeeping staff, and Director of Nursing provided conflicting information about who was responsible for these tasks, revealing a lack of a clear process or schedule for maintaining the refrigerators. The Administrator and Director of Operations acknowledged that housekeeping was supposed to check the temperatures, discard expired foods, and clean the refrigerators daily. However, the observations and interviews indicated that this was not being done consistently, leading to potential health risks for the residents. The facility's failure to maintain kitchen equipment and ensure proper food storage practices demonstrated significant deficiencies in their operations, potentially affecting all residents.
Failure to Develop a QAPI Plan
Penalty
Summary
The facility failed to develop a Quality Assurance and Performance Improvement Plan (QAPI). The facility's policy, revised in February 2020, outlines the responsibilities of the QAPI committee, including overseeing the implementation of the QAPI plan, identifying and correcting quality deficiencies, and monitoring the effectiveness of corrective actions. However, the facility did not have a QAPI plan in place, despite having policies that describe the QAPI process. During an interview, the Administrator admitted that they are starting fresh with QAPI and could not find any past documentation. The facility has no Performance Improvement Projects (PIPs) in place and plans to have weekly QAPI meetings. The absence of a QAPI plan was confirmed through both interviews and record reviews, indicating a significant gap in the facility's quality assurance and performance improvement efforts.
Failure to Implement QAPI Plan
Penalty
Summary
The facility failed to ensure the Quality Assurance Performance Improvement (QAPI) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. The facility's policy required an ongoing, facility-wide, data-driven QAPI program focused on indicators of care outcomes and quality of life for residents. However, the review of the QAPI committee notes showed no evidence of key personnel such as the Medical Director, Director of Nursing, or Infection Preventionist attending the meeting. Additionally, there were no Performance Improvement Projects (PIPs) in place, which are essential for addressing and correcting quality deficiencies. During an interview, the Administrator admitted that they were starting fresh with QAPI and could not find any past documentation of QAPI activities. Despite having a recent meeting, the facility had no PIPs in place and planned to have weekly QAPI meetings moving forward. This lack of documentation and absence of PIPs indicated a failure to systematically analyze underlying causes of systemic quality deficiencies and implement corrective actions, as required by their QAPI policy. This deficiency had the potential to affect all residents in the facility, which had a census of 92 at the time of the survey.
Failure to Maintain Quarterly QAPI Meetings with Required Members
Penalty
Summary
The facility failed to maintain quarterly Quality Assurance and Performance Improvement (QAPI) committee meetings with the required members. The facility's policy, revised in March 2020, mandates that the QAPI committee includes the Administrator, Director of Nursing Services, Medical Director, Infection Preventionist, and representatives from various departments. However, a review of an Inservice Log dated 04/26/24 showed no evidence of the Medical Director, Director of Nursing, or Infection Preventionist attending the meeting. Additionally, the Administrator admitted to not finding documentation of past QAPI meetings and confirmed that no Performance Improvement Projects (PIPs) were in place. During interviews, the Administrator and Director of Operations acknowledged the expectation for the facility to hold QAPI meetings at least quarterly with the required members present. Despite the recent meeting, the lack of documentation and absence of key members indicate non-compliance with the facility's QAPI policy. The facility census at the time was 92 residents.
Failure to Notify Residents and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify residents and/or their representatives in writing of transfers or discharges to a hospital, including the reasons for the transfer, and did not notify the Office of the State Long-Term Care Ombudsman. This deficiency was identified for 10 residents out of a sample of 19, with the facility's census being 92. The facility's policy required that a Transfer to Another Facility form be filled out, explaining the reason for the transfer and the bed hold policy, and that this information be communicated to the resident or their representative. However, this procedure was not followed for the sampled residents, as there was no documentation of written notification to the residents or their representatives, nor was there any notification to the Ombudsman at the time of transfer to the hospital. The Social Services Director confirmed that they do not issue written transfer/discharge notices for hospital transfers, and the Administrator and Director of Operations stated that they would expect staff to notify the resident or their representative in writing and send a copy to the Ombudsman. Resident #2 was transferred to the hospital multiple times without written notification to the resident or their representative, and without notifying the Ombudsman. Similar deficiencies were found for Resident #4, who was transferred to the hospital on multiple occasions without the required notifications. Resident #11's medical record also showed a lack of documentation for written notification to the resident or their representative and the Ombudsman during a hospital transfer. Resident #14 experienced multiple hospital transfers without the necessary written notifications, and the same issue was found for Resident #52, who was transferred to the hospital three times without proper documentation. Other residents, including Resident #56, Resident #64, Resident #67, Resident #85, and Resident #444, also experienced hospital transfers without the required written notifications to themselves or their representatives and without notifying the Ombudsman. The facility's failure to follow its own policy and regulatory requirements for notifying residents, their representatives, and the Ombudsman in writing during hospital transfers was a consistent issue across multiple cases, as confirmed by interviews with the Social Services Director and the facility's administration.
Failure to Provide RN Coverage
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, as required. This deficiency had the potential to affect all residents, with a facility census of 92. The nursing schedules from February 1, 2024, through April 30, 2024, revealed that there were 11 days without any RN scheduled. Specific dates without RN coverage included February 17, March 2, 3, 16, 17, 30, 31, and April 13, 14, 27, 28. During an interview on May 7, 2024, the Administrator acknowledged the expectation for RN coverage for at least eight hours a day, seven days a week. Additionally, the facility did not provide an RN coverage policy.
Failure to Notify Residents of Survey Results
Penalty
Summary
The facility failed to notify residents of the availability and location of the most recent survey results in an accessible location. This deficiency was identified during a resident council meeting where multiple residents collectively stated they were unaware of a binder containing survey results or its placement. The facility's census was 92 at the time. The Administrator admitted during an interview that the survey results had been misplaced following an administration change. A new survey binder was eventually created and placed on the front table, but this was after the deficiency was noted.
Inconsistent Documentation of Code Status
Penalty
Summary
The facility failed to consistently document the code status for two residents, leading to discrepancies in their medical records. For one resident, the medical record showed conflicting information with both full code and Do Not Resuscitate (DNR) statuses documented. The resident had a care plan that listed both statuses with corresponding interventions and goals. Interviews with the resident and staff revealed confusion about the resident's current code status, with the resident indicating a change from hospice to full code, which was not consistently reflected in the documentation. For another resident, the medical record also showed conflicting information with both full code and DNR statuses documented. The care plan listed a DNR status, but staff interviews revealed inconsistencies in how code statuses were communicated and documented. Certified Nurse Assistants (CNAs) and the Director of Nursing (DON) provided different methods for determining code status, including lists at the nurse's station and symbols on resident doors, leading to further confusion. The Administrator and Director of Operations confirmed that the code status should be consistently reflected throughout the resident's chart, which was not the case for these residents.
Failure to Maintain a Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents. Observations of a resident's room on multiple occasions revealed that the oxygen concentrator had debris on the filter and the left side of the concentrator. Additionally, there were twenty drywall patches on the walls and corners of the room that were not painted over. Another room was observed to have stained privacy curtains with a brown substance, and a different room had missing bottom drawers from the closet and bent trim. These observations indicate a lack of adherence to the facility's general cleaning procedure, which requires reporting dirty curtains, burnt-out light bulbs, and missing items to the housekeeping supervisor for maintenance repairs. During an interview, the Administrator and Director of Operations acknowledged that they would expect curtains to be clean and free from dirt, debris, and stains, oxygen concentrators to be cleaned weekly, and closets and drawers to be in working condition. They also stated that they would expect the walls of resident rooms to be free from drywall patches after maintenance has had a reasonable amount of time to paint over them. The failure to meet these expectations was evident in the observed conditions of the resident rooms, indicating a deficiency in maintaining a safe, clean, comfortable, and homelike environment for the residents.
Failure to Provide Adequate Discharge Documentation
Penalty
Summary
The facility failed to provide adequate discharge documentation for a resident transferred to another facility. Specifically, the facility did not include a discharge summary or recapitulation of the resident's stay, which is required to ensure a safe and effective transition of care. The facility's policy mandates that a discharge summary and post-discharge plan be developed, including a recapitulation of the resident's stay and a final summary of the resident's status at the time of discharge. However, the medical record for the resident in question showed no such documentation upon their transfer to another facility. Interviews with facility staff revealed a misunderstanding or misapplication of the discharge policy. The Social Services Director indicated that discharge summaries are not typically filled out for residents transferred to another facility, and the Administrator confirmed this practice. The Director of Operations also stated that discharge summaries are only completed when a resident is discharged to go home, not when transferring to another nursing home. This practice is inconsistent with the facility's written policies and resulted in the failure to provide necessary discharge documentation for the resident.
Failure to Inform Residents of Bed Hold Policy
Penalty
Summary
The facility failed to inform residents and/or their legal representatives in writing of the bed hold policy at the time of transfer to the hospital for ten residents out of 19 sampled residents. The facility's policy required that the bed hold policy be explained and documented in writing upon obtaining a discharge order for hospital transfer. However, the medical records for the ten residents showed no documentation that the bed hold policy was communicated in writing during their transfers. This included multiple instances of hospital transfers and readmissions for each resident, with no written notification provided as required by the facility's policy. During interviews, the Social Services Director admitted that they do not issue a written copy of the bed hold policy to residents or their representatives when residents are sent to the hospital, as it was included in the initial admission package. The Administrator and Director of Operations stated that they expect staff to inform the resident or resident representative in writing of the bed hold policy upon hospitalization, indicating a discrepancy between the facility's policy and actual practice. This failure to provide written notification of the bed hold policy at the time of transfer was identified as a deficiency by the surveyors.
Failure to Complete Significant Change MDS Assessments
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment for two residents following their discharge from hospice services. For Resident #6, the medical record showed a quarterly MDS assessment indicating hospice services on 01/28/23 and a discharge from hospice services on an unspecified date. However, the facility did not complete a significant change MDS within 14 days after the discharge. Similarly, for Resident #67, the medical record showed a significant change MDS indicating the resident no longer received hospice services and a discharge date from hospice services, but the facility again failed to complete a significant change MDS within the required 14-day timeframe. During interviews, the Administrator, Director of Operations, and MDS Coordinator all acknowledged that the MDS should be updated and completed within the required timeframes as per the Resident Assessment Instrument (RAI) Manual. The MDS Coordinator specifically noted that a significant change MDS should be completed with each hospice admission and discharge to accurately reflect the resident's current condition. The failure to adhere to these requirements resulted in the deficiency noted in the report.
Inaccurate MDS Documentation for Multiple Residents
Penalty
Summary
The facility failed to document accurate Minimum Data Set (MDS) assessments for five residents, leading to discrepancies in their medical records. Resident #2's quarterly MDS assessment incorrectly indicated the use of insulin, despite no such order being present in the medical record. Resident #6's annual MDS assessment inaccurately marked Parkinson's disease and omitted diagnoses of GERD, macular degeneration, and glaucoma. Additionally, the quarterly MDS assessment for Resident #6 incorrectly indicated a life expectancy of less than six months following discharge from hospice services. Resident #9's quarterly MDS assessment incorrectly included a diagnosis of PTSD, which was not present in the medical record. Resident #64's quarterly MDS assessment failed to mark several diagnoses, including cardiac dysrhythmias, GERD, dementia, and anxiety. Resident #69's annual MDS assessment omitted diagnoses of heart failure, pneumonia, and Vitamin B-12 deficiency anemia. Interviews with facility staff, including the Social Services Director, Administrator, Director of Operations, and MDS Coordinator, confirmed the inaccuracies in the MDS assessments. The MDS Coordinator acknowledged that all active diagnoses should be reflected in Section I of the MDS and that non-insulin diabetes medication should not be coded as insulin. The facility's policy on MDS completion and submission timeframes, revised in October 2023, mandates that assessments be completed and submitted based on the current requirements published in the Resident Assessment Instrument (RAI) Manual. The deficiencies indicate a failure to adhere to these guidelines, resulting in inaccurate documentation of residents' conditions.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update and revise care plans with specific interventions to meet the individual needs of two residents. Resident #67, who was admitted with chronic kidney disease, cellulitis, GERD, insomnia, and heart failure, had orders for meropenem, normal saline flush, and PICC dressing changes. However, the care plan revised on 05/02/24 did not address the PICC line, which is a critical component of the resident's treatment plan. This omission indicates a lack of thorough analysis and updating of the care plan based on the resident's current medical needs and interventions as required by the facility's policy. Similarly, Resident #444, admitted with bacteremia, Type 2 diabetes, congestive heart failure, acute osteomyelitis, and a non-pressure chronic ulcer, had orders for daptomycin and PICC dressing changes. The care plan revised on 04/22/24 also failed to address the PICC line. During an interview, the Administrator and Director of Operations acknowledged that care plans should reflect the current condition of the resident and should be updated by facility staff when the responsible Registered Nurse is unavailable. This failure to update care plans as per the facility's policy resulted in deficiencies in the care provided to these residents.
Failure to Follow Physician's Orders and Obtain Treatment Orders
Penalty
Summary
The facility failed to follow physician's orders for two residents and did not obtain a treatment order for one resident. Resident #11 had an order for levothyroxine to be taken every morning on an empty stomach, but the medication administration times ranged from 7:46 A.M. to 12:45 P.M., with the medication being administered late on 20 out of 64 days. Additionally, Resident #11 was observed wearing prevalon boots on multiple occasions without a treatment order for them. The Assistant Director of Nursing acknowledged the lack of an order for the boots and mentioned that staff sometimes remove them because they get hot and itchy. Resident #56 also had an order for levothyroxine to be taken every morning, but the medication administration times ranged from 7:01 A.M. to 12:34 P.M., with the medication being administered late on 30 out of 64 days. The resident's thyroid stimulating hormone (TSH) levels were abnormally high, indicating improper administration of the medication. Interviews with the Director of Nursing, a Licensed Practical Nurse, and a Certified Medication Technician confirmed that levothyroxine should be given on an empty stomach or at bedtime, and the resident's TSH labs supported that the medication was not being administered correctly.
Failure to Follow PICC Line Care Protocols
Penalty
Summary
The facility failed to ensure staff provided necessary care and services in accordance with professional standards of practice for two residents. For Resident #67, the staff did not follow policies and procedures regarding PICC line care and administration of IV antibiotics. The resident's PICC line dressing, dated 04/20/24, was not changed weekly as required, and the infusion was not disconnected or flushed promptly after completion. The Director of Nursing and an LPN were unaware of the resident's PICC line, indicating a lack of communication and oversight in the facility's care processes. For Resident #444, the staff also failed to adhere to PICC line care protocols. The resident's PICC line dressing, dated 04/24/24, was not changed weekly, and there was blood around the catheter site. An LPN experienced difficulty flushing the line, which was found to be pulled out approximately three centimeters and appeared kinked. The night nurse had accidentally pulled the line partway out during a dressing change, and the PICC line company had to be contacted to replace the line. The Director of Nursing confirmed that the staff should not attempt to reinsert a displaced PICC catheter. Interviews with the residents and staff revealed that the facility did not follow physician orders and professional standards for PICC line care. The Administrator and Director of Operations acknowledged that a registered nurse should complete PICC line dressing changes and that the line should be flushed and cared for according to physician orders. They also stated that infusions should be disconnected promptly after completion and that staff should not attempt to reinsert a displaced PICC catheter.
Failure to Screen Residents for Tuberculosis
Penalty
Summary
The facility failed to screen four residents for Tuberculosis (TB) as per their policy. The policy mandates that all residents be screened for TB infection and disease, with specific guidelines for new admissions, readmissions, and annual screenings. However, the medical records of four residents showed lapses in compliance. Resident #4 was admitted on an unspecified date and had an annual TB test on 02/20/24, but there was no read date or documentation of TB testing or screening. Resident #11, admitted on an unspecified date, had their last annual screening on 01/19/23, with no subsequent documentation. Similarly, Resident #69 and Resident #444, both admitted on unspecified dates, had their last annual screenings on 01/19/23, with no further documentation of TB testing or screening since then. The facility's failure to adhere to its TB screening policy was identified through observation, interview, and record review. The policy requires annual risk assessments and regular testing for residents with specific health conditions or risk factors. Despite these requirements, the facility did not document the necessary TB screenings for the four residents, indicating a significant lapse in infection prevention and control measures. The facility's census at the time was 92, highlighting the potential for broader non-compliance issues within the resident population.
Inadequate Dining Room Space
Penalty
Summary
The facility failed to provide a dining room large enough to accommodate the residents, affecting one resident out of 19 sampled residents and three residents outside the sample, with the potential to affect all residents. Observations showed that the main dining room had 11 round tables with room for four chairs at each table, totaling 44 seating places, and one table with five residents. Additionally, an unknown staff member was observed squeezing between tables and bumping two residents' chairs while they were eating. The assisted dining room had 21 seating places, making a total of 65 seating places in the two dining rooms, which was insufficient for the facility census of 92 residents. Interviews with residents revealed dissatisfaction with the dining room arrangements. One resident mentioned taking food back to their room because the dining room was overcrowded. Another resident stated that the dining room was too full, causing some residents to leave and come back when a seat was available. A third resident expressed frustration over the inability to choose where to sit and noted that residents in wheelchairs were required to sit on one side of the dining room. The Director of Operations acknowledged that residents could eat in either dining room and that staff should be able to pass trays without bumping into residents, but the observations and resident interviews indicated otherwise.
Failure to Maintain Safe Overbed Lighting
Penalty
Summary
The facility failed to provide a safe and functional environment for the residents by allowing items to be stored on top of overbed light fixtures in three rooms. This practice was observed on multiple occasions, with items such as stuffed animals and crafts being placed on the light fixtures. These observations were made on different dates and times, indicating a recurring issue. The facility census was 92, and the deficient practice had the potential to affect all residents and staff in the facility. The facility did not have a specific policy for overbed lighting safety, although the facility's admission packet did include a rule against storing personal items on the overhead light fixture due to safety hazards. During an interview, the Administrator and Director of Operations acknowledged that items should not be placed on the light fixtures due to the potential fire hazard. Specific observations included three stuffed animals on the light over the bed in one room, two heart-shaped crafts in another, and various other items in additional rooms. These observations were consistent over two days, highlighting a lack of adherence to safety protocols and the facility's own rules and regulations regarding the storage of personal items.
Inadequate In-Service Education for CNAs
Penalty
Summary
The facility failed to conduct at least twelve hours of nurse aide in-service education per year, affecting two out of two sampled Certified Nurse Assistants (CNA) D and E. CNA D, hired on 04/10/19, had only one hour of annual in-service training for the period from April 2023 through April 2024. Similarly, CNA E, hired on 03/11/19, had only four hours of annual in-service training for the same period. During an interview, the Administrator acknowledged that CNAs are expected to have at least twelve hours of in-service education per year. The facility did not provide an in-service training policy.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility staff failed to post the required daily nurse staffing information, which includes the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, in a prominent location readily accessible to residents and visitors. The facility census was 92. Observations from 04/29/24 through 05/03/24 showed that the required daily nurse staffing information was not found near any of the nurse's stations or the main lobby where it would be easily visible to residents and visitors. During an interview on 05/03/24, a Certified Nurse Aide (CNA) stated that the daily nurse staffing information was posted in the nurse's office behind the nurse's station, making it inaccessible to residents or visitors. The Administrator confirmed on 05/07/24 that she would expect the facility staffing to be posted in a prominent location that is readily accessible to residents and visitors.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 872 citations issued within 25 miles in the last 12 months — including the 14 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fenton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Delmar Gardens Of Meramec Valley | 0.2 mi | ★★★★★ | 5 | 0 |
| Fieser Nursing Center | 1.4 mi | ★★★★★ | 22 | 0 |
| Friendship Village Sunset Hills | 3.1 mi | ★★★★★ | 0 | 0 |
| South County Health Care Center | 3.2 mi | ★★★★★ | 0 | 0 |
| Fountain Care At Sunset Hills | 3.5 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Maple Grove Wellness & Rehabilitation.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.