Deficiency Records for Maple Heights Nursing and Rehabilitative Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Maple Heights Nursing and Rehabilitative Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-07-17 | 2023-08-24 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-07-17 | 2023-08-24 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-07-17 | 2023-08-24 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-07-17 | 2023-08-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-17 | 2023-08-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-17 | 2023-08-24 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-07-17 | 2023-08-24 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-07-17 | 2023-08-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-17 | 2023-08-24 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-06-15 | 2023-07-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-15 | 2023-07-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-15 | 2023-07-19 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-06-15 | 2023-07-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-15 | 2023-07-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-15 | 2023-07-19 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-06-15 | 2023-07-19 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-06-15 | 2023-07-19 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-06-15 | 2023-07-19 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-06-15 | 2023-07-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-15 | 2023-07-19 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-06-15 | 2023-07-19 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-06-15 | 2023-07-19 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-06-15 | 2023-07-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-06-15 | 2023-07-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-24 | 2023-01-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-06 | 2022-06-24 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-11-30 | 2022-01-03 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-11-30 | 2022-01-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-30 | 2022-01-03 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-11-30 | 2022-01-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-30 | 2022-01-03 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-11-30 | 2022-01-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-11-30 | 2022-01-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-30 | 2022-01-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-11-30 | 2022-01-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-11-30 | 2022-01-03 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-11-04 | 2021-12-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-11-04 | 2021-12-14 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-11-04 | 2021-12-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-12 | 2020-01-24 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-12-12 | 2020-01-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-12-12 | 2020-01-24 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-12-12 | 2020-01-24 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-12-12 | 2020-01-24 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-12-12 | 2020-01-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-12 | 2020-01-24 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-10-15 | 2019-11-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-10-15 | 2019-11-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-15 | 2019-11-15 | N |
