Maple Grove Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Maple Grove Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF919Aug 18, 2021

  Based on observation, record review, resident, staff, physician and contractor interviews for the facility's call system, the facility failed to have a functioning call system and 12 of 14 alert and oriented residents (Resident #17, Resident #18, Resident #19, Resident #20, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, Resident #26 and Resident #27) did not have an alternate means to call for staff assistance. The call system was in disrepair throughout the entire facility causing the residents to express feelings of being scared, concerned and not cared for by the facility. Immediate Jeopardy began on 8-6-21 when it was observed resident's call lights were not working and they did not have an alternate means to call for assistance. […]

• Immediate jeopardy, patternF742Dec 13, 2022

  Based on record review, staff, family, and the Psychiatric Mental Health Nurse Practitioner (PMHNP) interviews, the facility failed to provide care and treatment to a resident who had a mental health diagnosis and had an increase in a behavior of refusing food, activities of daily living care (ADL), and pressure ulcer treatments for greater than two weeks. The facility did not actively pursue options to address the mental health issue when the resident had an increase in the refusal of food, ADL care, and treatment of the pressure ulcer. The increase in the refusals continued until the Resident was discovered to be unresponsive on 12/3/2022 and was sent to an acute care hospital. […]

• Immediate jeopardy, isolatedF925Dec 13, 2022

  Based on observations, record review and staff, Hospital Nurse, Emergency Medical Services Staff and Pest Control Representative interviews the facility failed to implement fly reduction measures to protect vulnerable residents with wounds from the development of maggots and failed to ensure doors to the outside were not left open allowing the entry of flies into the facility. This resulted in 1 of 3 residents (Resident #1) reviewed for wound care developing maggots on her abdominal pannus (the area of excess skin and fat that hangs over the pubic region), buttocks, perineum (the thin layer of skin between the vaginal opening and anus), every fold of the groin, and sacral wound. […]

• Immediate jeopardy, isolatedF600Jun 23, 2022

  Based on record review and staff interview, the facility failed to protect a resident who was severely cognitively impaired (Resident #1) from sexual abuse from another resident who was moderately cognitively impaired (Resident #2). Resident #2 willfully entered Resident #1's room, removed his pants, unfastened Resident #1's brief and climbed on top of her with the intention of having sexual intercourse with her. Resident #1 was sent to the hospital emergency department and had a sexual assault nurse exam (SANE). There was no obvious trauma on exam. This deficient practice affected one of three residents reviewed for abuse. Findings included: Resident #1 was admitted to the facility on [DATE], Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Immediate jeopardy, isolatedF689Nov 15, 2021

  Based on record review, observation, resident, staff and physician interviews, the facility failed to ensure 1 of 3 residents (Resident #1), who was on an anticoagulant (blood thinner) and required extensive assistance with Activities of Daily Living (ADL) care, was provided care safely to prevent injury. During a bed bath provided by nursing assistant (NA) #1 on 10-26-21, Resident #1 was positioned on her left side on an air mattress when NA #1 turned away and Resident #1 rolled off the bed onto the floor resulting in 4 fractures to her left leg, acute blood loss, and a 10-centimeter laceration to her left lower leg. Resident #1 was hospitalized for 3 days. […]