Phoenix of Maple Heights

In the surveyor’s words

From the most serious findings on record at Phoenix of Maple Heights, in the surveyor’s own words.

• Actual harm, isolatedF684Oct 20, 2021

  Based on interview, record review, and facility policy review, the facility failed to ensure timely interventions were implemented and failed to timely address signs and symptoms of a stroke for Resident #32. Actual harm occurred on 04/06/21 when Resident #32 experienced a significant change in condition including slurred speech, facial droop, right sided weakness and difficulty with ambulation. Resident #32 was subsequently admitted to the hospital on 04/14/21 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 81. […]

• No harm, potential for more than minimal, widespreadF584Jun 13, 2024

  Based on observation, interviews, and review of the facility policy and procedure, the facility failed to ensure the residents' environment was clean, sanitary, and was in good repair. This had the potential to affect all residents residing in the facility. The census was 88. Findings include: Observations during a tour of the facility on 06/12/24 from 1:43 P.M. to 4:49 P.M. with two surveyors revealed: Residents #56 and #81's room revealed the non- skid strips on floor were coming up off the floor and the privacy curtain rod off was the track. Residents #57 and #139's room revealed the baseboard heater cover was missing, exposing the heating element. The wall outside of the locked unit revealed the baseboard heater cover was hanging off and exposing the heating element. […]

• No harm, potential for more than minimal, widespreadF727Jun 13, 2024

  Based on record review and staff interview the facility failed to maintain the services of a registered nurse for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 88 residents currently residing in the facility. Findings include: Review of the Payroll Based Journal (PBJ) staffing data report for quarter 1 (10/01/23 - 12/31/23) revealed six identified dates (10/07/23, 10/21/23, 11/18/23, 11/19/23, 12/17/23, and 12/31/23) that had no registered nurse coverage. Review of the following staffing dates on 06/05/24 at 7:46 A.M. […]

• No harm, potential for more than minimal, widespreadF868Jun 13, 2024

  Based on record review and staff interview, the facility failed to ensure the medical director was an active participant of the Quality Assessment and Assurance (QAA) committee. This had the potential to affect all residents. The facility census was 88. Findings include: Review of the facility sign-in sheets for the QAA meeting minutes for the meetings dated 07/06/23 through 05/01/24 revealed no evidence the medical director attended the meetings. Interview on 06/11/24 at 12:54 P.M. with the Administrator verified the medical director's signature was not on any of the sign-in sheets for the QAA meetings. The Administrator stated the medical director would at times attend the meetings via phone but was unable to indicate which meetings the medical director attended via phone.

• No harm, potential for more than minimal, widespreadF880Jun 13, 2024

  Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review the facility failed to maintain an effective infection control program, failed to ensure appropriate personal protective equipment (PPE) was utilized during resident care, and failed to ensure annual Tuberculosis (TB) assessments were completed annually since the last annual survey dated 04/28/22. This had the potential to affect all 88 residents residing in the facility. Findings Include: 1. The entrance conference was held on 06/03/24 at 9:19 A.M. with the Administrator and Chief Clinical Officer (CCO) #490. […]