Avenir at Maple Grove

In the surveyor’s words

From the most serious findings on record at Avenir at Maple Grove, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Nov 24, 2021

  Based on observation, interview, and record review, the facility failed to ensure two residents were free from neglect. On 11/20/21, Registered Nurse (RN) D failed to administer scheduled medications and check blood sugar levels as ordered by the physician for two residents (Resident #8 and #12). Resident #12 had a diagnoses of high blood pressure and diabetes and did not receive his/her scheduled blood pressure medications, oral diabetic medication, and sliding scale insulin. Resident #12 required emergent treatment in the hospital that included intravenous insulin for extremely elevated blood sugar, as well as treatment for extremely elevated blood pressure. […]

• Immediate jeopardy, isolatedF600Nov 18, 2021

  Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #9) was free from abuse. On 9/2/21, Resident #9 reported that on 9/1/21, Certified Nurse Aide (CNA) A (agency staff) slapped him/her on the face and told him/her to shut up. Resident #9 said it hurt and he/she was afraid of CNA A. A sample of 18 residents was selected for review. The facility census was 46. On 11/18/21 at 7:18 P.M., the administrator was notified of the past non-compliance immediate jeopardy (IJ) which occurred on 9/1/21. On 9/2/21, the administrator identified CNA A had physically and verbally abused Resident #9. Upon discovery, staff contacted the police, conducted an investigation, and notified appropriate parties. […]

• Immediate jeopardy, isolatedF689Mar 3, 2021

  Based on observation, interview and record review, the facility failed to provide protective oversight for one resident (Resident #1) with a history of elopement of 15 sampled residents. The facility failed to put effective interventions in place resulting in the resident eloping from the facility twice. The resident left the facility without staff knowledge in sub-zero temperatures on 2/14/21. The resident left the facility again without staff knowledge on 2/22/21 after dark, and walked into the street. Another facility resident observed Resident #1 walking into traffic. The facility census was 38. The administrator was notified on 2/23/21 at 7:30 P.M. of an Immediate Jeopardy (IJ) which began on 2/14/21. […]

• Actual harm, isolatedF684Dec 14, 2022

  Based on interview and record review the facility failed to ensure one resident (Resident #1) who staff assessed as a fall risk, of three sampled residents, received treatment and care in accordance with professional standards of practice. Resident #1 fell and was not thoroughly assessed for injuries prior to transfer from the floor to the wheelchair and remained in the wheelchair for approximately four hours with no additional assessments or care provided. Approximately four hours after the fall, staff discovered blood on the table and on the resident's pants. The resident had a visible fracture of the left forearm with a puncture wound. The resident was transferred to the hospital and diagnosed with a compound fracture (broken bones that pierce the skin). […]

• Actual harm, isolatedF689Nov 18, 2021

  Based on interview and record review, the facility staff failed to use a gait belt during a transfer for two residents (Resident #5 and Resident #8). Resident #8 sustained a fractured right arm as a result of the improper transfer. Resident #5 sustained injury during the transfer. A sample of 18 residents was selected for review. The facility census was 46. Record review of the facility's gait belt policy revised on 1/30/2014 showed the following: -All employees are given a gait belt at time of employment. If you do not have a gait belt at the start of your shift, you must notify your charge nurse and she will obtain one for you. […]