Mapleton Post Acute

Inspectors wroteBased on record review and interviews, the facility failed to inform one (#3) of ten residents reviewed for beneficiary notices and appeal rights out of 18 sample residents of changes in their services covered by Medicare in a timely manner. Specifically, the facility failed to provide a written notification of Medicare Notice of Non-Coverage (NOMNC) letter to Resident #3's representative when the resident's Medicare Part A covered skilled services were ending.

Inspectors wroteBased on record review and interviews, the facility failed to revise and implement an effective discharge plan for one (#16) of three residents reviewed for discharge planning out of 18 sample residents. Specifically, the facility failed to: -Ensure the discharge planning was process was documented, including the reason for discharge in Resident #16's electronic medical record (EMR); -Notify Resident #16 and Resident #16's representative, in writing, of the discharge, including the reason for the move, the effective date of discharge, the location where the resident was being discharged to, a statement of the resident's appeal rights and the name, address and telephone number of the office of the state long term care ombudsman; and, -Notify the facility's ombudsman of Resident #16's discharge in writing.

Inspectors wroteBased on observation and interviews, the facility failed to ensure all drugs and biological used in the facility were properly stored and labeled in two out of two units. Specifically, the facility failed to: -Ensure medications that were self administered were stored securely at the bedside for Resident #33; -Ensure a medication storage room was securely locked; -Ensure medications that were not administered were not left unsecured at Resident #28's bedside; and, -Ensure medications were not left unattended on medication and treatment carts.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide services for three (#39, #22 and #52) of five residents out of 32 sample residents according to professional standards of practice. Specifically, the facility failed to monitor vital signs prior to the administration of a blood pressure medication for Resident #39, Resident #22 and Resident #52.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to prevent the development and transmission of disease and infection on two out of two units. Specifically, the facility failed to: -Ensure glucometers were sanitized appropriately between uses; and, -Ensure the resident's rooms were cleaned in a sanitary manner.

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement an effective discharge plan for two (#128 and #125) of three residents reviewed for discharge planning out of 32 sample residents. Specifically, the facility failed to provide an appropriate discharge planning process for Resident #128 and #125.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure each resident with limited range of motion received appropriate treatment and services to increase range of motion (ROM) and/or prevent further decrease in ROM for one (#42) of two residents reviewed for restorative services out of 32 sample residents. Specifically, the facility failed to ensure Resident #42 was provided with a restorative nursing program to maintain and/or prevent deterioration of her current level of function and mobility. I. Facility policy and procedure The Restorative Nursing Program policy and procedure, reviewed January 2024, was received by the nursing home administrator (NHA) on 12/5/24 at 9:17 a.m. It read in pertinent part, It is the policy of this facility to provide maintenance and restorative services designed to improve residents' abilities to the highest practicable level. [...]

Inspectors wroteBased on record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans and resident preferences for one (#2) of three residents reviewed for pain management out of five sample residents. The facility failed to ensure Resident #2, with a diagnosis of chronic low back pain, low back compression fractures, spinal stenosis (spaces inside bones get small putting pressure on spinal cord), spinal fusion, history of infection in the back with sepsis (infection of the bloodstream), repeat falls and anxiety, was administered scheduled pain medication as ordered. Resident #2 was interviewed about her pain during the survey, she cried and sobbed, hardly able to speak when she described how she was not administered her pain medication due to it not being available. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were kept free from significant medication errors for five (#2, #3, #4, #5 and #1) of five residents reviewed for medication errors. Specifically, the facility failed to ensure Residents #2, #3, #4, #5 and #1 received medications according to the physician's orders which resulted in significant medications errors. The failure to ensure medications were given according to physician orders affected all five sample residents and was recognized to affect all other residents prescribed medications in the facility. Record review and interviews showed the facility systematically had problems with the pharmacy filling orders and staff ordering medications.

Inspectors wroteBased on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns were implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to quality of care.

Inspectors wroteBased on record review and interviews, the facility failed to ensure mandatory submission of direct care staffing based on payroll roll data. Specifically, the facility failed to ensure staffing data entered in the Payroll-Based Journal (PBJ) system was accurate.

Inspectors wroteBased on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to resident rights, quality of life and quality of care.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure five (#62, #13, #217, #5 and #49) of six residents reviewed out of 38 sample residents for assistance with activities of daily living (ADL) received appropriate treatment and services to maintain or improve his or her abilities. Specifically, the facility failed to: -Ensure dependent Residents #62, #13, #217 and #49 were provided with showers; and, -Reposition Resident #5 in accordance with her plan of care.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills to ensure the residents received the care and services they required as determined by resident assessments and individual plans of care. Specifically, the facility failed to consistently provide adequate nursing staff which considered the acuity and diagnoses of the facility's resident population in accordance with the facility assessment, resident census and daily care required by the residents. Cross-reference citations: -F677 activities of daily living; -F689 accident hazards; and, -F692 hydration.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure the medication error rates were less than five percent for two residents (#15 and #11). Specifically, the facility had a medication error rate of 21 percent, which was eight errors out of 38 opportunities for error.

Inspectors wroteBased on observations and interviews, the facility failed to ensure all drugs and biologicals used in the facility were properly stored in three out of three medication carts. Specifically, the facility failed to ensure medication carts were locked when left unattended.

Inspectors wroteBased on interviews and record review, the facility failed to timely and thoroughly investigate an alleged violation of physical abuse for one (#219) of three reviewed for abuse out of 38 sample residents. Specifically, the facility failed to investigate an abuse allegation reported by Resident #219 to her hospice nurse and licensed practical nurse (LPN) #3.

Inspectors wroteBased on record review and interviews the facility failed to ensure one (#40) of one out of 38 sampled residents with a pressure ulcer received the necessary treatment and services according to professional standards of practice. Specifically, the facility failed to: -Identify the continued system breakdown of ensuring changes to treatment orders were translated from the physician wound notes to the treatment administration record (TAR) timely, specifically, that Resident #40 received wound treatments as ordered by the physician; and -Ensure interventions ordered by the physician were included and updated on the comprehensive care plan.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#13 and #7) of two residents received adequate supervision to prevent accidents out of 38 sample residents. Specifically, the facility failed to ensure two staff members were present during the transfers of Resident #7 and Resident #13 using a mechanical lift.

Inspectors wroteBased on observations, resident interview, record review, and staff interviews, the facility failed to ensure residents maintained continence or received treatment and services to restore continence to the extent possible for one (#219) of two residents out of 38 sample residents. Specifically failed to ensure Resident #219's catheter was secured.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure one (#15) out of one resident reviewed for hydration of 38 sample residents was provided sufficient fluids to maintain hydration and health. Specifically, the facility failed to: -Offer and encourage Resident #15 to drink sufficient fluids with a history of dehydration, an altered liquid consistency (thickened liquids) and diuretic medication and provide care planned interventions to address her increased risk of dehydration; and, -Ensure Resident #15 was served the appropriate liquid consistency.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#40) of three out of 38 sample residents who required respiratory care were provided such care and services consistent with professional standards of practice. Specifically, the facility failed to ensure Resident #40 received supplemental oxygen according to physician orders.

Inspectors wroteBased on observations, record review and interviews; the facility failed to provide food that accommodated resident allergies, intolerances and preferences for one (#44) of two residents out of 38 sample residents. Specifically, the facility failed to provide food that accommodated Resident #44's wheat allergy.

Inspectors wroteBased on record review and interviews, the facility failed to meet all the requirements for the provision of hospice care for one (#219) of two out of 38 sampled residents. Specifically, the facility failed to ensure the hospice agency notes regarding Resident #219 care was easily accessible to facility staff in an attempt to effectively coordinate care with the hospice agency and there was no end of life care plan.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the environment remained as free of accident hazards as possible for seven (#60, #2, #47, #26, #33, #221 & #32) of seven out of 27 sample residents. Specifically, the facility failed to: -Provide adequate supervision for Resident #32 who had dementia and a history of being physically and verbally aggressive; -Implement behavioral management interventions to protect other residents from Resident #32's, at times, physical and verbal aggression; and -Monitor for the effectiveness of behavioral management interventions and modify when necessary. Cross-reference to: -F609 Reporting of Alleged Violations, because the facility failed to make a report to the State Survey Agency as required by law when Resident #32 grabbed another resident by the wrist, which caused bruising. [...]

Inspectors wroteBased on record review and interview, the facility failed to report an allegation of abuse for one (#32) out of two sample residents. Specifically, the facility failed to make a report to the State Survey Agency as required by law when Resident #32 grabbed another resident by the wrist, which caused bruising. Cross reference to: -F610 Investigate/Prevent/Correct Alleged Violations, because the facility failed to perform and document interviews with other residents who may have encountered Residents #10 and #32, in order to identify other care concerns, abuse allegations, which would assist the facility in developing interventions to keep other residents safe. -F689 Free of Accident Hazards/Supervision/Devices, because the facility failed to provide adequate supervision of Resident #32, who had dementia and a history of being physically and verbally aggressive. [...]

Inspectors wroteBased on record review and interviews, the facility failed to have evidence that all violations of abuse, exploitation or mistreatment were thoroughly investigated for two (#10 and #32) out of two residents reviewed for alleged allegations of abuse out of two sampled residents. Specifically, the facility failed to perform and document interviews, during the facility's investigation into alleged allegations of resident-to-resident abuse, with other residents who may have encountered Residents #10 and #32, in order to identify other care concerns and/or abuse allegations, which would assist the facility in developing interventions to keep residents safe. Cross-reference to: -F609 Reporting of Alleged Violations, because the facility failed to make a report to the State Survey Agency as required by law when Resident #32 grabbed another resident by the wrist, which caused bruising. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to collaborate with the hospice provider to attain or maintain the highest practicable physical, mental, and psychosocial well-being of one (#46) of one residents out of 27 sample residents reviewed for hospice services. Specifically, the facility failed to demonstrate consistent collaboration of care was occurring between the facility and the hospice provider to ensure accurate and timely documentation for Resident #46.