Inspection Reports for Resthaven Maple Woods

The inspection was conducted as a renewal inspection to assess the facility's compliance with applicable licensing statutes and rules.

The facility was found to be in substantial compliance with the public health code and administrative rules regulating Home for the Aged facilities. No deficiencies or further recommendations were noted.

The inspection was conducted as a special investigation following a complaint alleging the facility did not follow Covid-19 protocols resulting in a resident testing positive and that the facility was not providing care in accordance with a resident's service plan.

The investigation found no violation regarding Covid-19 protocols as the facility followed health department guidelines and contained cases without an outbreak. However, a violation was established due to discrepancies between the resident's service plan and care round logs, indicating inconsistent toileting assistance and care documentation.

The complaint alleged the facility did not follow Covid-19 protocols resulting in Resident A testing positive and that the facility was not providing care according to Resident A's service plan. The Covid-19 protocol violation was not substantiated, but the care plan violation was substantiated.

The investigation was initiated due to allegations of short staffing, broken air conditioning, and bed bugs on the second-floor memory care unit of Resthaven Maple Woods.

The investigation established a violation for short staffing on 9/4/2023 where one care staff member was left alone to care for 20 residents. No violations were found regarding the air conditioning or bed bugs as the facility took immediate corrective actions. An additional violation was found for Resident A not having a bed, as the recliner used is not considered a bed.

The complaint was received anonymously on 09/20/2023 alleging short staffing, broken air conditioning, and bed bugs on the second-floor memory care unit. The short staffing allegation was substantiated; the air conditioning and bed bug allegations were not substantiated.

The inspection was conducted as a Renewal Licensing Study to evaluate compliance with state regulations and determine if the facility license should be renewed.

The facility was found to be in non-compliance with multiple rules including failure to post resident rights policy, incomplete tuberculosis screening for residents and employees, medication handling violations, improper storage of garbage and linens, unlabeled food items, and unsafe storage of hazardous materials. All violations require corrective action.

The inspection was conducted due to a complaint alleging that the facility did not provide Resident A appropriate supervision during a behavioral incident related to safety of self and staff.

The investigation found that the facility demonstrated understanding of Resident A's diagnosis and behaviors and had interventions in place, but it could not be determined how Resident A obtained scissors used in the incident or why a fire extinguisher was found in Resident A's room. The facility did not designate a level of supervision imperative for a person with impaired cognition, resulting in a violation.

The complaint alleged that the facility did not provide Resident A appropriate supervision during a behavioral incident involving safety risks to self and staff. The violation was established based on interviews, on-site inspection, and documentation review.

The visit was conducted as part of an original licensing study to approve the expansion of rooms 202 to 207, 209 to 213, and 215 to 216 as an extension of the current memory care unit for the home for the aged (HFA).

The inspection found that the specified rooms meet the requirements for licensed beds with adequate space, built-in closets, and in-room bathrooms. Day/dining space remains adequate to support the proposed expansion of the memory care unit.

The inspection was conducted as a special investigation following an anonymous complaint alleging that staff did not administer Resident A’s medications in accordance with physician orders.

The investigation found that Resident A’s PRN medications were administered according to physician orders; however, the medication administration record (MAR) for September 20, 2022, was incomplete for several medications, with no documentation confirming administration or refusal, constituting a violation of medication documentation rules.

The complaint alleged that staff did not administer Resident A’s medications in accordance with physician orders. The violation was substantiated based on incomplete medication documentation in the MAR.

The purpose of this addendum is to describe a change in room function and the development of an Alzheimer’s program, including the establishment of a secured memory unit in the facility.

The secured memory unit consists of 13 single occupancy and one double occupancy rooms with appropriate resident amenities and safety features, including magnetic locks and staff communication radios. The Alzheimer’s program statement is compliant with regulatory requirements, and the revised floor plan does not constitute a major building modification.