Complete Care at Maple Grove LLC

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Sep 12, 2024

  Based on interview and record review, the facility failed to ensure each resident (R) received adequate supervision to prevent accidents for 1 of 3 residents (R2) reviewed for altered diets out of a total sample of 6. R2 has had two choking episodes within a month's time. On [DATE], R2 choked on a hot dog. The Heimlich maneuver was performed, and R2 was sent to the emergency room and admitted to the hospital for acute hypoxic respiratory failure, aspiration event/choking on a hot dog, and aspiration pneumonitis. On [DATE], R2 was to receive a Level 6: soft and bite sized (no hot dogs), thin liquids consistency diet. […]

• Immediate jeopardy, isolatedF689Dec 4, 2023

  Based on interview and record review, the facility did not ensure that each staff implemented proper safety interventions as directed by a resident's plan of care and did not ensure residents were free from accidents and hazards for 1 of 3 residents (R1) reviewed for falls. On [DATE], a Certified Nursing Assistant (CNA) attempted to provide care to R1 without maintaining the proper safety interventions as directed in R1's care plan. R1 rolled off the bed and fell approximately 2 feet to the floor, hitting her head. R1 suffered multiple fractures and a subarachnoid hemorrhage (bleeding in the space surrounding the brain), resulting in death. This created a finding of immediate jeopardy that began on [DATE]. […]

• Actual harm, isolatedF689May 5, 2025

  Based on observation, interview, and record review, the facility did not ensure fall interventions were in place per the care plan and each residents received adequate supervision to prevent accidents for 3 of 23 sampled Residents (R27, R59, & R82) reviewed for falls and supervision. R27 is being cited at scope/severity level 3 (isolated/actual harm). R27 was a fall risk and has had 23 falls since admission on [DATE]. R27's falls typically occurred in the dining room or resident room; there were similarities to the falls including location and time of day. The facility completed a root cause analysis (RCA) and collected data on the falls; however, there is no evidence the interdisciplinary team (IDT) comprehensively reviewed the data or considered increasing R27's supervision. […]

• Actual harm, isolatedF689Mar 28, 2025

  Based on interview, record review, and policy review the facility failed to ensure that the facility was free of accident hazards in 1 of 7 residents R9 reviewed for accident hazards of 14 sample residents. The facility failed to prevent a fall for R9 Findings include: Review of the facility's policy titled, Fall Prevention Program, dated 02/28/25, indicated Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Definitions: A fall is an event in which an individual unintentionally comes to rest on the ground, floor or other level, but not as result of an overwhelming external force .Policy Explanation and Compliance Guidelines: 1. […]

• Actual harm, isolatedF689Oct 21, 2024

  Based on observation, interview, and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (R5) reviewed for supervision and accidents. R5 was served coffee while in his bed and dropped the coffee cup in the bed on his right side which pooled up against him. R5 sustained superficial partial thickness burns to right flank and right buttocks, estimated approximately 7% Total Body Surface Area (TBSA). Facility had no process in place regarding safety to residents with hot liquid temping or any type of safety assessment. After the incident occurred, coffee brewers were temped at 185 Fahrenheit. […]