Inspection Reports for
Maple Manor Christian Home Inc

The facility was found not in compliance with several Life Safety Code requirements including incomplete fire alarm system policies, inadequate fire department connection signage, unsealed gaps around sprinkler heads, corridor doors with holes allowing smoke passage, lack of annual fire door inspections, incomplete testing and documentation of patient care related electrical equipment, and improper storage of oxygen cylinders.

The facility failed to follow documentation procedures for dispensed medications on the Controlled Drug Record of administered narcotics for 5 of 24 residents observed. Discrepancies were found between medication counts and documentation for residents 16, 15, 13, 49, and 50.

Complaint IN00446181 was substantiated with a federal/state deficiency cited (F604). Complaints IN00446569 and IN00446803 had no deficiencies related to the allegations.

The facility was found deficient for failing to ensure a resident (Resident B) was free from physical restraints, specifically being restrained in place by locking wheelchair brakes and positioning arms across the chest. No deficiencies were cited for two of the complaints. The deficiency was corrected by the facility after education and systemic interventions.

Complaint IN00434474 was substantiated with a Federal/State deficiency cited as F600 related to abuse and neglect. The incident involved CNA 9 verbally and physically abusing Resident B on 5/12/24. The staff member was terminated and the facility implemented a systemic corrective plan including staff education and resident assessments.

The facility failed to ensure that staff to resident abuse did not occur for one resident (Resident B). Evidence included observation, interviews, record review, and video footage showing inappropriate behavior by a staff member toward the resident. The staff member was terminated and corrective actions were implemented.

At the PSR survey, the facility was found in compliance with Emergency Preparedness Requirements. However, the facility was found not in compliance with Life Safety Code requirements due to failure to properly enclose two former dumbwaiter shafts with the required fire resistance rating, posing a risk to residents, staff, and visitors. The deficiency was corrected by sealing the openings with drywall and fire caulk.

Complaint IN00424481 was substantiated with a Federal/State deficiency cited at F600 for neglect related to failure to respond appropriately to a resident fall.

The facility failed to ensure staff immediately responded and completed a full body assessment when Resident B fell. The RN involved did not assess the resident for injury and delayed assistance, constituting neglect.

The facility was found not in compliance with emergency preparedness training requirements, emergency power system maintenance, means of egress obstructions, door locking arrangements, hazardous area enclosures, sprinkler system installation, fire extinguisher maintenance, electrical receptacle standards, and use of extension cords. Corrective actions and plans of correction were provided for each deficiency.

Complaint IN00416292 was substantiated with a federal/state deficiency cited at F684 related to quality of care involving delayed insulin administration and blood sugar monitoring for Resident B.

The facility failed to ensure timely blood sugar level checks and insulin administration for a diabetic resident admitted on 8/23/23. The resident did not receive insulin orders entered into the system timely, resulting in delayed treatment and a high blood sugar reading of 600 mg/dl. The facility implemented new procedures to audit admission medication orders and educate staff on insulin and accu check order entry.

The facility was found in compliance with Emergency Preparedness Requirements. However, several Life Safety Code deficiencies were identified including corridor obstructions, outdated smoke alarms, cooktop safety issues, missing flame spread rated panel on attic access, lack of semi-annual fire alarm visual inspections, a malfunctioning fire alarm pull station, and incomplete sprinkler system inspections and maintenance.

The facility was found deficient in accurate skin assessments, timely care plan revisions, and proper treatment and monitoring of pressure ulcers and skin impairments, including issues related to a soft helmet fitting and monitoring. Several residents had pressure ulcers or skin breakdowns that were not properly documented or treated in a timely manner.