Maple Gardens Rehabilitiation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Maple Gardens Rehabilitiation and Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, patternF880Mar 30, 2021

  Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated [DATE], Nursing Home Guidance from the Centers for Disease Control (CDC), review of the facility's Coronavirus (COVID-19) policy and procedure, review of the facility's COVID-19 resident and employee positive test results, review of the facility's daily COVID-19 employee screening log, review of e-mail communications, review of timecards, review of text communications, review of audits and in-service records, staff and Local Health Department (LHD) staff interviews, the facility failed to implement effective and recommended infection control practices, including following CDC guidelines for excluding health care personnel, who have had contact with someone with… […]

• Immediate jeopardy, isolatedF600Mar 30, 2023

  Based on medical record review, review of a Self-Reported Incident (SRI), interviews with staff, residents, the law enforcement detective, and Sexual Assault Nurse Examiner (SANE), review of the police report, review of the Emergency Medical Services (EMS) report, review of the hospital records, review of the facility investigation, review of the SANE report, and policy review, the facility failed to ensure one resident (#49) was free from resident-to-resident sexual abuse. This resulted in Immediate Jeopardy and the potential for serious physical, mental and/or psychosocial harm on 02/26/23 at approximately 6:00 P.M., when Resident #25 entered Resident's 49's room and forcefully penetrated Resident #49's vagina with his fingers causing Resident #49 to have pain and bleeding while the… […]

• No harm, potential for more than minimal, widespreadF838Jan 16, 2025

  Based on observations, staff interviews, policy review and review of a facility emergency management plan, the facility failed to ensure there was an adequate amount of food available in the facility to account for scheduled meals and emergency situations. This had the potential to affect all 53 residents residing in the facility. Facility census was 53. Findings include: Tour of the facility kitchen with Dietary Supervisor #10 on 01/15/25 at 9:19 A.M. revealed the emergency food supply consisted of six cans (24 servings per can) of tuna; six cans (12 servings per can) of ravioli; 48 individual serving cans of a variety of soups; 72 orange juice, four ounces (oz) each; 12 packs of lemonade powder, each pack makes three gallons of lemonade; four five pound bags of dry milk; a box of… […]

• No harm, potential for more than minimal, widespreadF880Feb 5, 2021

  Based on review of facility screen logs, observations, staff interview, policy review and review of guidance from the Centers for Medicare and Medicaid Services (CMS) and Guidance from the Centers for Disease Control (CDC), the facility failed to ensure all employees or visitors were screened for Coronavirus Disease 2019 (COVID-19) prior to entrance into the facility, failed to clean/disinfect resident care equipment between resident use and failed to ensure a doffing location was appropriately set up with a trash receptacle for disposal of used personal protective equipment (PPE) and for individuals leaving the area to perform hand hygiene to potentially prevent the spread of COVID-19. This had the potential to affect all 60 residents residing in the facility. […]

• No harm, potential for more than minimal, widespreadF882Feb 5, 2021

  Based on review of training documentation and staff interview, the facility failed to have a designated infection preventionist employed in the facility at least part-time that had completed specialized training in infection prevention and control. This had the potential to affect all 60 residents residing in the facility. The facility census was 60. Findings include: Review of the Centers of Disease Control (CDC) training website for the Director of Nursing's (DON) training profile revealed all training modules had been successfully completed on May 19, 2019; however, further review revealed the training was not completed as the test was not successfully passed. Interview with the Director of Nursing (DON) on 01/27/21 at 12:30 P.M. […]