Maris Grove.

“Suspected abuse of a resident (resident grabbing another resident around the chest, resulting in scratches) was not reported to the local area agency on aging as required under the Older Adult Protective Services Act.”

“Resident home contracts for two residents were not signed by the residents themselves. The facility asserts that both residents were deemed incapable of making informed decisions by medical providers, and therefore their Power of Attorney signed the contracts instead.”

“Records for two residents do not contain statements signed by the residents acknowledging receipt of resident rights and complaint procedures information. The facility asserts that both residents were deemed incapable of making informed decisions and their Power of Attorney signed documents instead.”

“Several resident records were unlocked, unattended, and accessible in the first floor nurse's station, violating confidentiality requirements. Resident records must be secured and inaccessible to unauthorized persons.”

“Medline Remedy Essentials Cleanse Spray Cleaner, labeled for external use only with warnings about eye contact, was unlocked, unattended, and accessible to residents in the 3rd floor activity room bathroom. The residents, including those in the memory care unit, have not been assessed as capable of safely using or avoiding poisonous materials.”

“The handle to the 3rd floor linen closet door was broken and could not be closed securely, creating a surface hazard that is not in good repair.”

“A resident's most recent medical evaluation was completed in 2024, which does not comply with the requirement for at least annual medical evaluations. The previous evaluation was also not completed within the required annual timeframe.”

“Resident #1 exhibited sexually aggressive behaviors toward other residents, including making sexual comments to staff and residents, attempting physical contact of a sexual nature with other residents, and being found naked in another resident's bed. The facility failed to include these behaviors in the resident's assessment and support plan and did not re-evaluate or update the plan upon observing the aggressive behaviors.”

“Resident #1's initial assessment did not include the resident's wandering behavior into other residents' rooms, which was documented on the date the resident entered another resident's bed.”

“Resident #1's support plan did not define the resident's behaviors related to "actions and expressions towards others" or develop an appropriate plan to meet this identified need.”

“Medication record discrepancies were identified for a resident receiving memory care and hospice services with controlled narcotic concentrate ordered three times daily plus as-needed doses. The controlled narcotic log showed a count discrepancy on one date, and on another date a routine afternoon dosage was incorrectly recorded in the PRN (as-needed) log instead of the scheduled dosage log.”

“A resident suffered skin tears and dried blood on their hand after falling. Staff person D failed to report the incident to the nurse at 3:00am when it occurred and failed to render first aid, despite the resident requesting a band aid.”

“During an overnight fire drill on 12/30/22 at 4:55am, documentation showed 44 residents with only 1 staff member present, including three residents requiring assistance with ambulation and mobility. The deficiency was later determined to be a documentation error by the fire consultant company, not an actual staffing shortage.”