Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Maple Grove Wellness & Rehabilitation during CMS and state inspections, most recent first.
A nurse failed to verify a resident's identity and administered another resident's morphine sulfate and lorazepam, resulting in the resident experiencing adverse symptoms and requiring Narcan and hospital transfer. The nurse did not follow the facility's medication administration policy, including the required identity checks and communication with the resident.
Nineteen residents did not receive prescribed medications or treatments when an LPN refused to cover a hallway after another nurse left early, and the DON was unable to secure agency coverage in time. Residents with conditions such as diabetes, hypothyroidism, and heart disease missed critical care, and staff attempts to notify the DON during the shift were unsuccessful.
Facility staff did not notify the physician of a resident's urine culture and sensitivity results, which showed E. coli resistant to the prescribed antibiotic Bactrim DS. The resident, with multiple chronic conditions, was treated for cellulitis, but the required communication of lab results to the physician did not occur, as the Infection Preventionist failed to follow protocol.
The facility failed to provide the required minimum of two showers per week for five residents, leading to complaints and observations of poor hygiene. Residents with various medical conditions requiring assistance for bathing reported infrequent showers and unkempt appearances. The facility's policy was not followed, and the administrator acknowledged the expectation for regular showers.
The facility failed to repair essential kitchen equipment and ensure proper food storage in residents' personal refrigerators. Observations revealed malfunctioning kitchen appliances and expired, improperly stored food items. Interviews indicated a lack of clear responsibility and process for maintaining the refrigerators, leading to potential health risks for residents.
The facility failed to develop a Quality Assurance and Performance Improvement Plan (QAPI). Despite having policies outlining the QAPI process, the facility did not have a QAPI plan in place. The Administrator admitted they are starting fresh with QAPI and could not find any past documentation, with no Performance Improvement Projects (PIPs) in place.
The facility failed to ensure the QAPI committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. Key personnel did not attend the QAPI meeting, and no Performance Improvement Projects (PIPs) were in place. The Administrator admitted to starting fresh with QAPI and lacking past documentation, indicating a failure to address systemic quality deficiencies.
The facility failed to hold quarterly QAPI meetings with the required members, as mandated by their policy. A review showed no evidence of key members attending a recent meeting, and the Administrator admitted to not finding documentation of past meetings or having any PIPs in place. The facility census was 92 residents.
The facility failed to notify residents and/or their representatives in writing of transfers or discharges to a hospital, including the reasons for the transfer, and did not notify the Office of the State Long-Term Care Ombudsman. This deficiency was identified for 10 residents out of a sample of 19, with the facility's census being 92.
The facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, affecting all residents. Nursing schedules from February to April 2024 showed 11 days without RN coverage. The Administrator acknowledged the expectation for RN coverage, and the facility lacked an RN coverage policy.
The facility failed to notify residents of the availability and location of the most recent survey results. Multiple residents were unaware of a binder containing survey results, and the Administrator admitted the results had been misplaced following an administration change. A new survey binder was eventually created and placed on the front table.
The facility failed to consistently document the code status for two residents, leading to discrepancies in their medical records. Interviews with staff revealed confusion about the methods for determining code status, resulting in conflicting information being recorded.
The facility failed to provide a safe, clean, comfortable, and homelike environment. Observations revealed debris on a resident's oxygen concentrator, unpainted drywall patches, stained privacy curtains, and missing closet drawers. The Administrator and Director of Operations acknowledged these issues, indicating a deficiency in maintaining the expected standards.
The facility failed to provide adequate discharge documentation for a resident transferred to another facility, including a discharge summary and recapitulation of the resident's stay. Interviews with staff revealed a misunderstanding of the discharge policy, leading to the omission of required documentation.
The facility failed to inform residents and/or their legal representatives in writing of the bed hold policy at the time of transfer to the hospital for ten residents. Despite the facility's policy requiring written notification, the Social Services Director admitted that this was not done, and the Administrator and Director of Operations expected staff to provide this information, highlighting a discrepancy between policy and practice.
The facility failed to complete significant change MDS assessments within the required 14-day timeframe for two residents following their discharge from hospice services. The Administrator, Director of Operations, and MDS Coordinator acknowledged the oversight, which did not comply with the RAI Manual requirements.
The facility failed to document accurate MDS assessments for five residents, leading to discrepancies in their medical records. Errors included incorrect indications of insulin use, inaccurate diagnoses, and omissions of several medical conditions. Interviews with staff confirmed these inaccuracies, highlighting a failure to adhere to the facility's MDS completion and submission guidelines.
The facility failed to update and revise care plans for two residents, omitting critical interventions such as PICC line management. This deficiency was acknowledged by the Administrator and Director of Operations, who stated that care plans should reflect the current condition of the residents.
The facility failed to follow physician's orders for two residents and did not obtain a treatment order for one resident. One resident had inconsistent administration times for levothyroxine and was observed wearing prevalon boots without an order. Another resident also had inconsistent levothyroxine administration times, leading to abnormal TSH levels.
The facility failed to follow professional standards for PICC line care for two residents. One resident's PICC line dressing was not changed weekly, and the infusion was not disconnected or flushed promptly. Another resident's PICC line dressing was not changed weekly, and the line was accidentally pulled out during a dressing change, requiring replacement. The facility did not adhere to physician orders and professional standards for PICC line care.
The facility failed to screen four residents for Tuberculosis (TB) as per their policy. Medical records showed lapses in compliance, with missing documentation for annual TB tests and screenings. The facility's census was 92, indicating potential broader non-compliance issues.
The facility failed to provide a dining room large enough to accommodate all residents, leading to overcrowding and discomfort. Observations showed insufficient seating, and residents reported having to take food back to their rooms or wait for a seat. The Director of Operations acknowledged the issue but did not provide a satisfactory solution.
The facility failed to maintain a safe environment by allowing items to be stored on overbed light fixtures in multiple rooms. Observations included stuffed animals and crafts placed on the lights, posing a potential fire hazard. The facility did not have a specific policy for overbed lighting safety, although the admission packet prohibited such practices.
The facility failed to provide at least twelve hours of annual in-service education for two CNAs, with one CNA receiving only one hour and another receiving four hours of training. The Administrator confirmed the expectation of twelve hours of training per year, and the facility lacked an in-service training policy.
The facility staff failed to post the required daily nurse staffing information in a prominent location readily accessible to residents and visitors. Observations showed the information was not visible near nurse's stations or the main lobby. A CNA confirmed it was posted in the nurse's office, making it inaccessible to residents or visitors. The Administrator expected the information to be posted in a prominent location.
Failure to Prevent Significant Medication Error Due to Improper Resident Identification
Penalty
Summary
A significant medication error occurred when a nurse administered another resident's prescribed medications—morphine sulfate and lorazepam oral concentrate—to a cognitively intact resident with multiple chronic conditions, including diabetes, chronic kidney disease, heart failure, COPD, chronic respiratory failure, and chronic pancreatitis. The nurse failed to verify the resident's identity, did not explain the medications being administered, and did not confirm the resident's name prior to administration. The nurse was running behind on the medication pass and, in haste, called out the intended recipient's name, to which the wrong resident responded, and then administered the medications without further verification. Shortly after receiving the incorrect medications, the resident experienced nausea and a rapid decline in condition, including changes in vital signs and mentation. The resident reported that the nurse did not communicate or identify herself, nor did she provide any information about the medications being given. The error was discovered when the resident questioned what had been administered and another nurse intervened to monitor the resident's condition. The facility's medication administration policy required verification of resident identity and adherence to the seven rights of medication administration, including the right resident, right medication, and right dose. The nurse involved admitted to not following these protocols due to being in a hurry. The incident resulted in the resident requiring administration of Narcan and transfer to the hospital for further evaluation.
Failure to Administer Medications and Treatments Due to Staffing Refusal
Penalty
Summary
The facility failed to follow physician's orders for 19 residents on the 100 hall, resulting in missed administration of critical medications and treatments. The review of medical records and medication administration records revealed that residents with diagnoses such as Type II Diabetes Mellitus, Hypothyroidism, Coronary Heart Disease, pneumonia, COPD, and Muscular Dystrophy did not receive prescribed medications, including various types of insulin, Levothyroxine, antibiotics, pain medication, and inhalation treatments. Blood sugar checks and other ordered care were also not performed as required by the residents' care plans and physician orders. The deficiency occurred during the night shift when only one nurse, an LPN, remained after the scheduled nurse for the 200 hallway left early. The LPN assigned to the 100 hallway refused to provide care or administer medications to the residents on that hall, stating discomfort with covering both hallways due to limited experience at the facility. The Director of Nursing (DON) was informed of the staffing issue and attempted to secure an agency nurse, who was expected to arrive by 11:00 P.M., but did not arrive until the morning. The DON left the facility after giving the keys to the LPN, who refused to accept responsibility for the 100 hallway. Throughout the night, no medications or treatments were administered to any residents on the 100 hallway. Staff, including a CNA, attempted to contact the DON to report the ongoing issue, but did not receive a response until after the shift. The following morning, the LPN confirmed to the DON that no care had been provided to the 100 hallway residents, and subsequently resigned. The facility did not provide a policy on medication administration when requested.
Failure to Notify Physician of Antibiotic-Resistant UTI Lab Results
Penalty
Summary
Facility staff failed to ensure proper antibiotic stewardship for a resident when they did not notify the resident's physician of the results from a urine culture and sensitivity (C&S) test. The resident, who had a history of diabetes, chronic kidney disease stage 2, COPD, hypertension, and adult failure to thrive, complained of burning during urination and had a urine sample collected. The physician was contacted for other symptoms and prescribed Bactrim DS for cellulitis, but there was no documentation that the physician was informed of the urine C&S results, which later showed Escherichia coli resistant to Bactrim DS. The facility's policy required staff to communicate pertinent clinical information, including lab results, to physicians to promote appropriate diagnosis and antibiotic prescribing. However, the Infection Preventionist, who was responsible for reviewing lab results and notifying the physician, did not follow this protocol. The Director of Nursing confirmed that the physician was not made aware of the urine C&S results, and the physician stated that a different antibiotic would have been prescribed if notified. There was no documentation that the alternate physician reviewed the lab results during a subsequent visit.
Failure to Provide Adequate Showering for Residents
Penalty
Summary
The facility failed to provide a minimum of two showers per week for five out of six sampled residents, potentially affecting all residents in the facility with a census of 92. The facility's policy stated that residents should be offered a shower at least once weekly and as requested, but this was not adhered to. The Resident Council Meeting Minutes also indicated ongoing complaints about the lack of showers. Resident #1, with diagnoses including supra ventricular tachycardia, respiratory failure, and depression, was observed with body odor and unkempt hair. The resident reported receiving showers only once or twice a month, despite needing assistance from staff. Resident #2, with severe cognitive impairment and multiple health issues, also reported not receiving the required showers, leading to greasy hair and dirty sheets. Both residents expressed dissatisfaction with the frequency of showers and the lack of staff assistance. Similarly, Residents #4, #5, and #6, all with various medical conditions requiring assistance for bathing, reported receiving showers far less frequently than the expected twice a week. Observations confirmed their unkempt appearance and body odor. Interviews with these residents revealed that they often requested showers but were either ignored or given excuses by the staff. The facility administrator acknowledged the expectation for showers to be given at least twice a week and for refusals to be documented.
Facility Fails to Maintain Kitchen Equipment and Ensure Proper Food Storage
Penalty
Summary
The facility failed to repair essential kitchen equipment, including the convection oven, stove top burners, flat top grill, and oven. Observations revealed significant issues such as a wooden block holding up the stove, rust covering the inside of the oven, missing knobs, and debris buildup. Interviews with the Dietary Manager and cooks confirmed that the malfunctioning equipment slowed down meal preparation and made it challenging to cook meals efficiently. Despite informing the administration, the necessary repairs or replacements were not made, affecting the dietary staff's ability to perform their duties effectively. The facility also failed to ensure that food stored in residents' personal refrigerators was maintained at safe temperatures and that expired foods were discarded. Observations of several residents' refrigerators showed expired and improperly stored food items, including undated leftovers and uncovered containers. Interviews with residents indicated that no one regularly checked their refrigerators for expired food, temperature, or cleanliness. The Dietary Manager, housekeeping staff, and Director of Nursing provided conflicting information about who was responsible for these tasks, revealing a lack of a clear process or schedule for maintaining the refrigerators. The Administrator and Director of Operations acknowledged that housekeeping was supposed to check the temperatures, discard expired foods, and clean the refrigerators daily. However, the observations and interviews indicated that this was not being done consistently, leading to potential health risks for the residents. The facility's failure to maintain kitchen equipment and ensure proper food storage practices demonstrated significant deficiencies in their operations, potentially affecting all residents.
Failure to Develop a QAPI Plan
Penalty
Summary
The facility failed to develop a Quality Assurance and Performance Improvement Plan (QAPI). The facility's policy, revised in February 2020, outlines the responsibilities of the QAPI committee, including overseeing the implementation of the QAPI plan, identifying and correcting quality deficiencies, and monitoring the effectiveness of corrective actions. However, the facility did not have a QAPI plan in place, despite having policies that describe the QAPI process. During an interview, the Administrator admitted that they are starting fresh with QAPI and could not find any past documentation. The facility has no Performance Improvement Projects (PIPs) in place and plans to have weekly QAPI meetings. The absence of a QAPI plan was confirmed through both interviews and record reviews, indicating a significant gap in the facility's quality assurance and performance improvement efforts.
Failure to Implement QAPI Plan
Penalty
Summary
The facility failed to ensure the Quality Assurance Performance Improvement (QAPI) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. The facility's policy required an ongoing, facility-wide, data-driven QAPI program focused on indicators of care outcomes and quality of life for residents. However, the review of the QAPI committee notes showed no evidence of key personnel such as the Medical Director, Director of Nursing, or Infection Preventionist attending the meeting. Additionally, there were no Performance Improvement Projects (PIPs) in place, which are essential for addressing and correcting quality deficiencies. During an interview, the Administrator admitted that they were starting fresh with QAPI and could not find any past documentation of QAPI activities. Despite having a recent meeting, the facility had no PIPs in place and planned to have weekly QAPI meetings moving forward. This lack of documentation and absence of PIPs indicated a failure to systematically analyze underlying causes of systemic quality deficiencies and implement corrective actions, as required by their QAPI policy. This deficiency had the potential to affect all residents in the facility, which had a census of 92 at the time of the survey.
Failure to Maintain Quarterly QAPI Meetings with Required Members
Penalty
Summary
The facility failed to maintain quarterly Quality Assurance and Performance Improvement (QAPI) committee meetings with the required members. The facility's policy, revised in March 2020, mandates that the QAPI committee includes the Administrator, Director of Nursing Services, Medical Director, Infection Preventionist, and representatives from various departments. However, a review of an Inservice Log dated 04/26/24 showed no evidence of the Medical Director, Director of Nursing, or Infection Preventionist attending the meeting. Additionally, the Administrator admitted to not finding documentation of past QAPI meetings and confirmed that no Performance Improvement Projects (PIPs) were in place. During interviews, the Administrator and Director of Operations acknowledged the expectation for the facility to hold QAPI meetings at least quarterly with the required members present. Despite the recent meeting, the lack of documentation and absence of key members indicate non-compliance with the facility's QAPI policy. The facility census at the time was 92 residents.
Failure to Notify Residents and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify residents and/or their representatives in writing of transfers or discharges to a hospital, including the reasons for the transfer, and did not notify the Office of the State Long-Term Care Ombudsman. This deficiency was identified for 10 residents out of a sample of 19, with the facility's census being 92. The facility's policy required that a Transfer to Another Facility form be filled out, explaining the reason for the transfer and the bed hold policy, and that this information be communicated to the resident or their representative. However, this procedure was not followed for the sampled residents, as there was no documentation of written notification to the residents or their representatives, nor was there any notification to the Ombudsman at the time of transfer to the hospital. The Social Services Director confirmed that they do not issue written transfer/discharge notices for hospital transfers, and the Administrator and Director of Operations stated that they would expect staff to notify the resident or their representative in writing and send a copy to the Ombudsman. Resident #2 was transferred to the hospital multiple times without written notification to the resident or their representative, and without notifying the Ombudsman. Similar deficiencies were found for Resident #4, who was transferred to the hospital on multiple occasions without the required notifications. Resident #11's medical record also showed a lack of documentation for written notification to the resident or their representative and the Ombudsman during a hospital transfer. Resident #14 experienced multiple hospital transfers without the necessary written notifications, and the same issue was found for Resident #52, who was transferred to the hospital three times without proper documentation. Other residents, including Resident #56, Resident #64, Resident #67, Resident #85, and Resident #444, also experienced hospital transfers without the required written notifications to themselves or their representatives and without notifying the Ombudsman. The facility's failure to follow its own policy and regulatory requirements for notifying residents, their representatives, and the Ombudsman in writing during hospital transfers was a consistent issue across multiple cases, as confirmed by interviews with the Social Services Director and the facility's administration.
Failure to Provide RN Coverage
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, as required. This deficiency had the potential to affect all residents, with a facility census of 92. The nursing schedules from February 1, 2024, through April 30, 2024, revealed that there were 11 days without any RN scheduled. Specific dates without RN coverage included February 17, March 2, 3, 16, 17, 30, 31, and April 13, 14, 27, 28. During an interview on May 7, 2024, the Administrator acknowledged the expectation for RN coverage for at least eight hours a day, seven days a week. Additionally, the facility did not provide an RN coverage policy.
Failure to Notify Residents of Survey Results
Penalty
Summary
The facility failed to notify residents of the availability and location of the most recent survey results in an accessible location. This deficiency was identified during a resident council meeting where multiple residents collectively stated they were unaware of a binder containing survey results or its placement. The facility's census was 92 at the time. The Administrator admitted during an interview that the survey results had been misplaced following an administration change. A new survey binder was eventually created and placed on the front table, but this was after the deficiency was noted.
Inconsistent Documentation of Code Status
Penalty
Summary
The facility failed to consistently document the code status for two residents, leading to discrepancies in their medical records. For one resident, the medical record showed conflicting information with both full code and Do Not Resuscitate (DNR) statuses documented. The resident had a care plan that listed both statuses with corresponding interventions and goals. Interviews with the resident and staff revealed confusion about the resident's current code status, with the resident indicating a change from hospice to full code, which was not consistently reflected in the documentation. For another resident, the medical record also showed conflicting information with both full code and DNR statuses documented. The care plan listed a DNR status, but staff interviews revealed inconsistencies in how code statuses were communicated and documented. Certified Nurse Assistants (CNAs) and the Director of Nursing (DON) provided different methods for determining code status, including lists at the nurse's station and symbols on resident doors, leading to further confusion. The Administrator and Director of Operations confirmed that the code status should be consistently reflected throughout the resident's chart, which was not the case for these residents.
Failure to Maintain a Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents. Observations of a resident's room on multiple occasions revealed that the oxygen concentrator had debris on the filter and the left side of the concentrator. Additionally, there were twenty drywall patches on the walls and corners of the room that were not painted over. Another room was observed to have stained privacy curtains with a brown substance, and a different room had missing bottom drawers from the closet and bent trim. These observations indicate a lack of adherence to the facility's general cleaning procedure, which requires reporting dirty curtains, burnt-out light bulbs, and missing items to the housekeeping supervisor for maintenance repairs. During an interview, the Administrator and Director of Operations acknowledged that they would expect curtains to be clean and free from dirt, debris, and stains, oxygen concentrators to be cleaned weekly, and closets and drawers to be in working condition. They also stated that they would expect the walls of resident rooms to be free from drywall patches after maintenance has had a reasonable amount of time to paint over them. The failure to meet these expectations was evident in the observed conditions of the resident rooms, indicating a deficiency in maintaining a safe, clean, comfortable, and homelike environment for the residents.
Failure to Provide Adequate Discharge Documentation
Penalty
Summary
The facility failed to provide adequate discharge documentation for a resident transferred to another facility. Specifically, the facility did not include a discharge summary or recapitulation of the resident's stay, which is required to ensure a safe and effective transition of care. The facility's policy mandates that a discharge summary and post-discharge plan be developed, including a recapitulation of the resident's stay and a final summary of the resident's status at the time of discharge. However, the medical record for the resident in question showed no such documentation upon their transfer to another facility. Interviews with facility staff revealed a misunderstanding or misapplication of the discharge policy. The Social Services Director indicated that discharge summaries are not typically filled out for residents transferred to another facility, and the Administrator confirmed this practice. The Director of Operations also stated that discharge summaries are only completed when a resident is discharged to go home, not when transferring to another nursing home. This practice is inconsistent with the facility's written policies and resulted in the failure to provide necessary discharge documentation for the resident.
Failure to Inform Residents of Bed Hold Policy
Penalty
Summary
The facility failed to inform residents and/or their legal representatives in writing of the bed hold policy at the time of transfer to the hospital for ten residents out of 19 sampled residents. The facility's policy required that the bed hold policy be explained and documented in writing upon obtaining a discharge order for hospital transfer. However, the medical records for the ten residents showed no documentation that the bed hold policy was communicated in writing during their transfers. This included multiple instances of hospital transfers and readmissions for each resident, with no written notification provided as required by the facility's policy. During interviews, the Social Services Director admitted that they do not issue a written copy of the bed hold policy to residents or their representatives when residents are sent to the hospital, as it was included in the initial admission package. The Administrator and Director of Operations stated that they expect staff to inform the resident or resident representative in writing of the bed hold policy upon hospitalization, indicating a discrepancy between the facility's policy and actual practice. This failure to provide written notification of the bed hold policy at the time of transfer was identified as a deficiency by the surveyors.
Failure to Complete Significant Change MDS Assessments
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment for two residents following their discharge from hospice services. For Resident #6, the medical record showed a quarterly MDS assessment indicating hospice services on 01/28/23 and a discharge from hospice services on an unspecified date. However, the facility did not complete a significant change MDS within 14 days after the discharge. Similarly, for Resident #67, the medical record showed a significant change MDS indicating the resident no longer received hospice services and a discharge date from hospice services, but the facility again failed to complete a significant change MDS within the required 14-day timeframe. During interviews, the Administrator, Director of Operations, and MDS Coordinator all acknowledged that the MDS should be updated and completed within the required timeframes as per the Resident Assessment Instrument (RAI) Manual. The MDS Coordinator specifically noted that a significant change MDS should be completed with each hospice admission and discharge to accurately reflect the resident's current condition. The failure to adhere to these requirements resulted in the deficiency noted in the report.
Inaccurate MDS Documentation for Multiple Residents
Penalty
Summary
The facility failed to document accurate Minimum Data Set (MDS) assessments for five residents, leading to discrepancies in their medical records. Resident #2's quarterly MDS assessment incorrectly indicated the use of insulin, despite no such order being present in the medical record. Resident #6's annual MDS assessment inaccurately marked Parkinson's disease and omitted diagnoses of GERD, macular degeneration, and glaucoma. Additionally, the quarterly MDS assessment for Resident #6 incorrectly indicated a life expectancy of less than six months following discharge from hospice services. Resident #9's quarterly MDS assessment incorrectly included a diagnosis of PTSD, which was not present in the medical record. Resident #64's quarterly MDS assessment failed to mark several diagnoses, including cardiac dysrhythmias, GERD, dementia, and anxiety. Resident #69's annual MDS assessment omitted diagnoses of heart failure, pneumonia, and Vitamin B-12 deficiency anemia. Interviews with facility staff, including the Social Services Director, Administrator, Director of Operations, and MDS Coordinator, confirmed the inaccuracies in the MDS assessments. The MDS Coordinator acknowledged that all active diagnoses should be reflected in Section I of the MDS and that non-insulin diabetes medication should not be coded as insulin. The facility's policy on MDS completion and submission timeframes, revised in October 2023, mandates that assessments be completed and submitted based on the current requirements published in the Resident Assessment Instrument (RAI) Manual. The deficiencies indicate a failure to adhere to these guidelines, resulting in inaccurate documentation of residents' conditions.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update and revise care plans with specific interventions to meet the individual needs of two residents. Resident #67, who was admitted with chronic kidney disease, cellulitis, GERD, insomnia, and heart failure, had orders for meropenem, normal saline flush, and PICC dressing changes. However, the care plan revised on 05/02/24 did not address the PICC line, which is a critical component of the resident's treatment plan. This omission indicates a lack of thorough analysis and updating of the care plan based on the resident's current medical needs and interventions as required by the facility's policy. Similarly, Resident #444, admitted with bacteremia, Type 2 diabetes, congestive heart failure, acute osteomyelitis, and a non-pressure chronic ulcer, had orders for daptomycin and PICC dressing changes. The care plan revised on 04/22/24 also failed to address the PICC line. During an interview, the Administrator and Director of Operations acknowledged that care plans should reflect the current condition of the resident and should be updated by facility staff when the responsible Registered Nurse is unavailable. This failure to update care plans as per the facility's policy resulted in deficiencies in the care provided to these residents.
Failure to Follow Physician's Orders and Obtain Treatment Orders
Penalty
Summary
The facility failed to follow physician's orders for two residents and did not obtain a treatment order for one resident. Resident #11 had an order for levothyroxine to be taken every morning on an empty stomach, but the medication administration times ranged from 7:46 A.M. to 12:45 P.M., with the medication being administered late on 20 out of 64 days. Additionally, Resident #11 was observed wearing prevalon boots on multiple occasions without a treatment order for them. The Assistant Director of Nursing acknowledged the lack of an order for the boots and mentioned that staff sometimes remove them because they get hot and itchy. Resident #56 also had an order for levothyroxine to be taken every morning, but the medication administration times ranged from 7:01 A.M. to 12:34 P.M., with the medication being administered late on 30 out of 64 days. The resident's thyroid stimulating hormone (TSH) levels were abnormally high, indicating improper administration of the medication. Interviews with the Director of Nursing, a Licensed Practical Nurse, and a Certified Medication Technician confirmed that levothyroxine should be given on an empty stomach or at bedtime, and the resident's TSH labs supported that the medication was not being administered correctly.
Failure to Follow PICC Line Care Protocols
Penalty
Summary
The facility failed to ensure staff provided necessary care and services in accordance with professional standards of practice for two residents. For Resident #67, the staff did not follow policies and procedures regarding PICC line care and administration of IV antibiotics. The resident's PICC line dressing, dated 04/20/24, was not changed weekly as required, and the infusion was not disconnected or flushed promptly after completion. The Director of Nursing and an LPN were unaware of the resident's PICC line, indicating a lack of communication and oversight in the facility's care processes. For Resident #444, the staff also failed to adhere to PICC line care protocols. The resident's PICC line dressing, dated 04/24/24, was not changed weekly, and there was blood around the catheter site. An LPN experienced difficulty flushing the line, which was found to be pulled out approximately three centimeters and appeared kinked. The night nurse had accidentally pulled the line partway out during a dressing change, and the PICC line company had to be contacted to replace the line. The Director of Nursing confirmed that the staff should not attempt to reinsert a displaced PICC catheter. Interviews with the residents and staff revealed that the facility did not follow physician orders and professional standards for PICC line care. The Administrator and Director of Operations acknowledged that a registered nurse should complete PICC line dressing changes and that the line should be flushed and cared for according to physician orders. They also stated that infusions should be disconnected promptly after completion and that staff should not attempt to reinsert a displaced PICC catheter.
Failure to Screen Residents for Tuberculosis
Penalty
Summary
The facility failed to screen four residents for Tuberculosis (TB) as per their policy. The policy mandates that all residents be screened for TB infection and disease, with specific guidelines for new admissions, readmissions, and annual screenings. However, the medical records of four residents showed lapses in compliance. Resident #4 was admitted on an unspecified date and had an annual TB test on 02/20/24, but there was no read date or documentation of TB testing or screening. Resident #11, admitted on an unspecified date, had their last annual screening on 01/19/23, with no subsequent documentation. Similarly, Resident #69 and Resident #444, both admitted on unspecified dates, had their last annual screenings on 01/19/23, with no further documentation of TB testing or screening since then. The facility's failure to adhere to its TB screening policy was identified through observation, interview, and record review. The policy requires annual risk assessments and regular testing for residents with specific health conditions or risk factors. Despite these requirements, the facility did not document the necessary TB screenings for the four residents, indicating a significant lapse in infection prevention and control measures. The facility's census at the time was 92, highlighting the potential for broader non-compliance issues within the resident population.
Inadequate Dining Room Space
Penalty
Summary
The facility failed to provide a dining room large enough to accommodate the residents, affecting one resident out of 19 sampled residents and three residents outside the sample, with the potential to affect all residents. Observations showed that the main dining room had 11 round tables with room for four chairs at each table, totaling 44 seating places, and one table with five residents. Additionally, an unknown staff member was observed squeezing between tables and bumping two residents' chairs while they were eating. The assisted dining room had 21 seating places, making a total of 65 seating places in the two dining rooms, which was insufficient for the facility census of 92 residents. Interviews with residents revealed dissatisfaction with the dining room arrangements. One resident mentioned taking food back to their room because the dining room was overcrowded. Another resident stated that the dining room was too full, causing some residents to leave and come back when a seat was available. A third resident expressed frustration over the inability to choose where to sit and noted that residents in wheelchairs were required to sit on one side of the dining room. The Director of Operations acknowledged that residents could eat in either dining room and that staff should be able to pass trays without bumping into residents, but the observations and resident interviews indicated otherwise.
Failure to Maintain Safe Overbed Lighting
Penalty
Summary
The facility failed to provide a safe and functional environment for the residents by allowing items to be stored on top of overbed light fixtures in three rooms. This practice was observed on multiple occasions, with items such as stuffed animals and crafts being placed on the light fixtures. These observations were made on different dates and times, indicating a recurring issue. The facility census was 92, and the deficient practice had the potential to affect all residents and staff in the facility. The facility did not have a specific policy for overbed lighting safety, although the facility's admission packet did include a rule against storing personal items on the overhead light fixture due to safety hazards. During an interview, the Administrator and Director of Operations acknowledged that items should not be placed on the light fixtures due to the potential fire hazard. Specific observations included three stuffed animals on the light over the bed in one room, two heart-shaped crafts in another, and various other items in additional rooms. These observations were consistent over two days, highlighting a lack of adherence to safety protocols and the facility's own rules and regulations regarding the storage of personal items.
Inadequate In-Service Education for CNAs
Penalty
Summary
The facility failed to conduct at least twelve hours of nurse aide in-service education per year, affecting two out of two sampled Certified Nurse Assistants (CNA) D and E. CNA D, hired on 04/10/19, had only one hour of annual in-service training for the period from April 2023 through April 2024. Similarly, CNA E, hired on 03/11/19, had only four hours of annual in-service training for the same period. During an interview, the Administrator acknowledged that CNAs are expected to have at least twelve hours of in-service education per year. The facility did not provide an in-service training policy.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility staff failed to post the required daily nurse staffing information, which includes the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, in a prominent location readily accessible to residents and visitors. The facility census was 92. Observations from 04/29/24 through 05/03/24 showed that the required daily nurse staffing information was not found near any of the nurse's stations or the main lobby where it would be easily visible to residents and visitors. During an interview on 05/03/24, a Certified Nurse Aide (CNA) stated that the daily nurse staffing information was posted in the nurse's office behind the nurse's station, making it inaccessible to residents or visitors. The Administrator confirmed on 05/07/24 that she would expect the facility staffing to be posted in a prominent location that is readily accessible to residents and visitors.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fenton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Delmar Gardens Of Meramec Valley | 0.2 mi | — | 5 | 0 |
| Fieser Nursing Center | 1.4 mi | — | 22 | 0 |
| Friendship Village Sunset Hills | 3.1 mi | — | 0 | 0 |
| South County Health Care Center | 3.2 mi | — | 0 | 0 |
| Fountain Care At Sunset Hills | 3.5 mi | — | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.