Inspection Reports for
The Maples at Har-Ber Meadows

The complaint investigation was substantiated as the facility confirmed the medication error involving Resident #84 and identified infection control lapses during wound care for Resident #2. The medication error involved administration of another resident's opioid medication, and the infection control issue involved failure to change gloves and perform hand hygiene. Family members were involved and requested emergency care for Resident #84.

The facility failed to prevent a significant medication error involving the administration of the wrong opioid medication to Resident #84, causing potential harm. Additionally, the facility failed to ensure proper infection control practices during wound care for Resident #2, specifically failure to change gloves and perform hand hygiene.

The complaint investigation found that Resident #84 was given an opioid medication belonging to another resident, which the resident was allergic to, causing lethargy and nausea. The family requested the resident be assessed in the emergency department. The medication error was confirmed by interviews with nursing staff, the Director of Nursing, the Administrator, and involved Licensed Practical Nurses. Corrective actions included in-service training on medication administration.

The facility failed to ensure Resident #84 was not given the wrong opioid medication, resulting in minimal harm or potential for actual harm. The medication error was confirmed through record reviews and interviews, and corrective actions including staff in-service training were implemented prior to the survey.

The complaint investigation was substantiated as the facility confirmed the medication error involving Resident #84. The resident was given another resident's opioid medication, causing adverse symptoms. The family requested emergency room assessment. The facility conducted interviews and in-serviced staff following the incident.

The facility failed to prevent a significant medication error when Licensed Practical Nurse (LPN) #1 administered the wrong opioid medication to Resident #84, who has known allergies to certain opioids. The resident experienced lethargy and nausea but had no lasting ill effects after being assessed and treated, including a visit to the emergency department. Corrective actions included staff in-service training on medication administration.

The complaint investigation was substantiated, revealing that Resident #84 was given an opioid medication they were allergic to, causing lethargy and nausea. The family requested emergency room evaluation. The facility acknowledged the medication error and provided staff in-service training. Infection control issues were also identified during wound care for Resident #2.

The facility failed to prevent a significant medication error involving Resident #84 who was given the wrong opioid medication, causing potential adverse effects. Additionally, the facility failed to ensure proper infection control practices during wound care for Resident #2, including failure to change gloves and perform hand hygiene appropriately.

The facility was found deficient in multiple areas including failure to provide meal preferences correctly, inadequate personal hygiene care for residents, insufficient RN coverage for 8 consecutive hours, failure to post nurse staffing information daily, discrepancies in narcotic medication records, failure to perform proper hand hygiene before serving meals, and failure to prevent cross-contamination of food between residents.

The complaint investigation found that the facility did not notify the responsible party of Resident #110's refusals of physical, occupational, and speech therapy. Interviews with staff confirmed lack of notification and documentation. The facility also failed to maintain required RN coverage and failed to post nurse staffing information properly.

The facility failed to notify the responsible party of Resident #110's refusals of therapy and treatment, and failed to ensure a Registered Nurse worked at least 8 consecutive hours daily. Additionally, the facility did not post nurse staffing information daily with required details such as facility name, census, and actual hours worked.

The complaint investigation focused on failure to notify the responsible party of Resident #110's refusals of therapy and care, and issues with nursing staffing coverage and posting of staffing information. Interviews with staff and review of records confirmed these failures.

The facility failed to notify the responsible party of Resident #110's refusals of therapy and other care, and failed to ensure a Registered Nurse worked at least 8 consecutive hours per day. Additionally, the facility did not post nurse staffing information daily with required details such as facility name, census, and actual hours worked.

The facility was found deficient in multiple areas including failure to provide preferred foods to a resident, inadequate nail and hair care for residents, failure to ensure an RN worked at least 8 consecutive hours daily, failure to post nurse staffing information daily, discrepancies in narcotic medication records, failure to perform proper hand hygiene before serving meals, and failure to prevent cross-contamination of food between residents.

The facility failed to ensure staff followed physician's orders for prescribed oxygen flow rates for Resident #105 and failed to ensure a physician order was obtained for oxygen administration for Resident #83. Interviews with nursing staff and the Director of Nursing confirmed responsibility for ensuring oxygen orders are followed and that oxygen use requires a physician's order.

The complaint investigation found substantiated deficiencies related to oxygen administration orders and adherence for two residents, with minimal harm or potential for actual harm and few residents affected.

The facility failed to ensure Resident #105 received oxygen at the prescribed flow rate of 3-6 liters per minute, with observations showing oxygen running at 1.5 liters per minute. Additionally, the facility failed to obtain a physician's order for oxygen administration for Resident #83, despite oxygen being administered at 2 liters per minute. Interviews with nursing staff and the Director of Nursing confirmed these failures and responsibility for ensuring orders are followed.

The facility failed to ensure that facial hair was removed to promote good hygiene and dignity for one resident (#3) who required assistance with activities of daily living. Interviews with staff confirmed that shaving female residents is the responsibility of CNAs and nurses and is considered a dignity issue. Documentation showed no refusal of shaving by the resident.

The facility failed to ensure that facial hair was removed to promote good hygiene and dignity for one resident (#3) who required assistance with activities of daily living. Interviews with staff confirmed that shaving female residents is the responsibility of CNAs and nurses and is considered important for dignity.