Inspection Reports for
Maple Grove Wellness &Amp; Rehabilitation

The facility had multiple deficiencies including failure to obtain informed consent for psychotropic medications, failure to provide accessible survey results, unsafe and unsanitary environment in shower rooms, failure to attempt gradual dose reductions for psychotropic medications, failure to notify residents of transfers and bed hold policies, failure to develop baseline care plans within 48 hours of admission, failure to provide scheduled showers, improper nephrostomy tube care, incomplete dialysis communication, lack of bed rail assessments and consents, incomplete CNA performance reviews and training, failure to conduct monthly pharmacist medication reviews, inadequate QAPI program implementation, infection control lapses, failure to maintain bed rail and mattress safety inspections, and unsafe storage of items on overbed light fixtures.

The complaint investigation revealed substantiated findings of medication administration failures affecting multiple residents and a significant medication error involving Resident #1 receiving another resident's medications, resulting in actual harm and emergency medical intervention.

The facility failed to follow physician's orders for 19 of 43 residents on the 100 hall, including missed medication administrations and blood sugar checks. Additionally, a significant medication error occurred when a nurse administered another resident's morphine and lorazepam to Resident #1, resulting in actual harm and hospitalization.

The facility failed to ensure proper antibiotic stewardship for one resident by not notifying the resident's physician of a urinary tract infection based on lab results. Additionally, the facility did not follow proper infection control reporting procedures for communicable diseases.

The complaint investigation found that the facility did not notify the physician of Resident #1's urine culture and sensitivity results dated 02/02/2025. The Director of Nursing confirmed the Infection Preventionist failed to follow protocol. The resident was discharged on 02/08/2025. The physician was unaware of the lab results and would have prescribed a different antibiotic if informed.

The facility failed to notify the physician of urine culture and sensitivity results for Resident #1, resulting in inappropriate antibiotic treatment. The Infection Preventionist responsible for reviewing lab results had left employment, and the policy to report lab results was not followed.

Complaint investigation related to failure to provide adequate showering to residents. The complaint number is MO00238847. The complaint was substantiated with findings of inadequate showering frequency and poor hygiene.

The facility failed to provide at least two showers per week for five of six sampled residents, resulting in poor hygiene conditions such as body odor and unkempt hair. Resident interviews and observations confirmed the inadequate showering frequency and lack of scheduled shower days documentation.

Complaints substantiated at F677 under complaint number MO00238847.

The facility failed to provide a minimum of two showers per week for five of six sampled residents, resulting in poor hygiene and body odor. Multiple residents' medical records and shower logs showed missed shower opportunities, and interviews confirmed inadequate assistance from staff.

The facility failed to maintain exit discharge pathways free of obstructions, ensure cooking facilities were free of grease accumulation, and restrict the use of combustible decorations. These deficiencies potentially affected all residents and staff.

The facility had multiple deficiencies including failure to notify residents of survey results, inconsistent documentation of code status, unsafe and unclean environment, inadequate discharge documentation and notification, incomplete MDS assessments, inaccurate care plans, failure to follow physician orders, lack of RN coverage, failure to post nurse staffing information, kitchen equipment disrepair, improper food storage, lack of QAPI plan and meetings, incomplete TB screening, inadequate dining room space, unsafe storage of items on overbed lights, and insufficient nurse aide in-service training.

The facility was found to have multiple deficiencies including failure to ensure resident dignity with catheter care, failure to provide a safe and comfortable environment, inadequate grievance policy implementation, incomplete comprehensive care plans, insufficient ADL care, failure to prevent decrease in range of motion, food safety violations, infection control issues, and incomplete immunization documentation.

The facility was found deficient in multiple areas including failure to maintain resident dignity regarding catheter care, inadequate maintenance and cleanliness of the environment, failure to follow grievance and care planning policies, inconsistent assistance with activities of daily living, poor infection control practices, and unsanitary food storage and preparation conditions.

The facility failed to properly store hand sanitizer, maintain the emergency generator, restrict temporary wiring, and properly store oxygen tanks. These deficiencies potentially affected all residents and staff.

The investigation was complaint-related focusing on care plan compliance and medication administration. The complaint was substantiated as deficiencies were found.

The facility was found to be in compliance with COVID-19 emergency preparedness requirements. However, deficiencies were found related to failure to meet professional standards of care in comprehensive care plans and medication administration, specifically regarding PICC line flush orders and documentation.

The facility was cited for multiple deficiencies including failure to develop and implement abuse/neglect policies, incomplete comprehensive care plans, inadequate dialysis documentation, insufficient registered nurse coverage, lack of nurse aide training, failure to post nurse staffing data, improper medication storage and labeling, and inadequate infection prevention and control measures.

The facility failed to maintain proper egress door locking arrangements, hazardous area protections, smoking regulations, electrical equipment safety, gas equipment storage, and oxygen storage in accordance with NFPA and state codes. Multiple deficiencies were identified affecting resident and staff safety during emergencies.

The facility was found to have multiple deficiencies including issues with management of personal funds, advance directives, Medicaid/Medicare coverage notices, transfer and discharge requirements, infection control, medication management, staffing, food safety, and resident care plans. The facility failed to meet several regulatory requirements as evidenced by interviews, record reviews, and observations.

The facility failed to maintain the kitchen range hood and fire extinguishers according to NFPA standards, did not have proper documentation for elevator inspections, and failed to maintain smoking area trash cans free of cigarette butts. These deficiencies potentially affected all residents and staff.

Complaint #MO140996 was investigated regarding failure to provide proper transfer/discharge notices and bed hold policy notifications. The complaint was substantiated as the facility failed to notify residents and representatives as required.

The facility failed to issue proper written discharge notices to residents or their representatives, failed to inform residents and families about the bed hold policy at the time of transfer, failed to develop and implement baseline care plans within 48 hours of admission, failed to label and store medications properly, failed to maintain sanitary food storage and preparation areas, failed to complete a comprehensive facility assessment, and failed to establish an effective infection prevention and control program.

The facility failed to maintain ceilings free of penetrations to resist smoke passage, maintain exit egress doors free from locking impediments, maintain emergency lighting and task lighting, ensure one-hour fire protection of hazardous areas, maintain the fire sprinkler system, maintain smoke barrier walls free of penetrations, and maintain smoking areas in accordance with NFPA regulations. These deficiencies affected all residents, staff, and occupants.