Maplewood Center

Inspectors wroteBased on interview and records reviewed, the facility failed to utilize the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurses Aides (CNA) that the RN was responsible for overseeing with provision of resident care. Specifically, the facility failed to provide the services of an RN for at least eight consecutive hours a day, seven days a week when no staffing waivers were in place for 16 days for the period of 10/1/25 to 12/31/25.

Inspectors wroteBased on observation and interview, the facility failed to properly follow food storage and infection control practices in the kitchen to prevent the risk of foodborne illness and contamination in accordance with professional standards for food service safety. Specifically, the facility failed to: A. properly date, label and prevent personal food from staff members from being stored with resident food in the kitchen to prevent the risk of foodborne illness and B. ensure non-kitchen staff members were not behind the tray line without performing proper infection control protocols to prevent contamination of ready-to-eat food.

Inspectors wroteBased on record review, interview and observation, the facility failed to implement a physician's order for repositioning one Resident (#8) out of 19 sampled residents. Specifically, nursing staff failed to offer to reposition Resident #8 every two hours for the management of moisture associated skin damage located on the buttocks.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#64) out of a total sample of 19 Residents. Specifically, the facility failed to ensure respiratory equipment was maintained in a sanitary condition as evidenced by the concentrator used to administer continuous oxygen had filters covered with a thick layer of white dust.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure services consistent with professional standards were provided for one Resident (#2) who required dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop working properly), out of total sample of 19 residents. Specifically, the facility failed to keep an updated communication book for dialysis care.

Inspectors wroteBased on observations, record review and interview, the facility failed to obtain a urine sample for laboratory services as ordered by the physician for one Resident (#2) out of a total sample of 19 Residents. Specifically, the facility failed to ensure that a urine sample was obtained to send to laboratory services, as ordered by the physician, to assess for a potential urinary tract infection.

Inspectors wroteBased on observations, record review and interview, the facility failed to accurately document in the electronic medical record for one Resident (#64), out of a total sample of 19 residents. Specifically, the facility failed to ensure staff members accurately documented that oxygen filters were cleaned when they were not.

Inspectors wrote4. For Resident #69 the facility failed to a. ensure that treatment provided to a stage 4 left heel pressure ulcer was implemented in accordance with the wound consultant, and b. failed to ensure treatment to a deep tissue injury to Resident #69's left heel was provided in accordance with the physician's orders. Resident #69 was admitted to the facility in November 2024 with diagnoses that include but not limited to paralytic gait, acute respiratory failure with hypoxia, unspecified severe protein-calorie malnutrition, and Alzheimer's disease. Review of Resident #69's Minimum Data Set (MDS) assessment, dated 5/16/25 indicated Resident #69 scored a 4 out of 15 on the Brief Interview for Mental Status exam, indicating he/she as having severe cognitive impairment, requires partial/moderate assistance with self-care activities including bathing, toileting and dressing. [...]

Inspectors wroteBased on interview and records reviewed, the facility failed to have sufficient qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being. Specifically, the facility failed to maintain sufficient staffing according to the facility assessment and facility staffing requirements.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the nursing staff were trained and demonstrated the competencies and skill sets necessary to provide the level and types of care and services needed as outlined in the Facility Assessment. Specifically, the facility failed to: 1. Ensure licensed nursing staff were trained and demonstrated competency to identify, assess, evaluate, intervene, and respond to change in condition of a wound and implement treatment recommendations, for 5 Residents (#24, #61, #30, #69, and #21), out of a total sample of 24 Residents. As a result of these failures, for Resident #24 the facility failed to implement recommendations from the Wound Consultant over a three-month period resulting in the deterioration of a pressure wound from a stage 2 pressure wound to an unstageable pressure wound. 2. [...]

Inspectors wroteBased on interview and records reviewed, the facility failed to utilize the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurses Aides (CNA) that the RN was responsible for overseeing with provision of resident care. Specifically, the facility failed to provide the services of a RN for at least eight consecutive hours a day, seven days a week when no staffing waivers were in place for seven days for the period of 10/1/24 to 12/31/24.

Inspectors wroteBased on interview and records reviewed, the facility failed to complete annual Certified Nurse Aide (CNA) performance reviews for 3 out of 3 eligible sampled CNA's.

Inspectors wroteBased on records reviewed and interviews, the facility failed to ensure it provided appropriate administrative oversight in a manner that enabled the facility to use its resources effectively to attain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility administration failed to ensure orientation, education and training was provided to all staff to provide competent, safe, and effective resident care as well as ensuring the governance and leadership members sustain a sufficient Quality Assurance Performance Improvement (QAPI) program during transitions in leadership and staffing. Specifically, the facility administration failed to: 1. [...]

Inspectors wroteBased on Facility Assessment review and staff interview, the facility failed to identify resources based on the resident population to determine the necessary care, support services, and educational resources (in-servicing) needed to care for residents. Specifically, the facility failed to address sufficient staffing, education resources and include a competency-based approach, including competencies necessary upon orientation and/or annually, to determine the knowledge and skills required among staff to ensure residents are able to maintain or attain their highest practicable physical, functional, mental, and psychosocial well-being and meet current professional standards of practice. [...]

Inspectors wrote2. Resident # 63 was admitted to the facility in [DATE] with diagnoses including hypertension. A review of the most recent Minimum Data Set (MDS) assessment, dated [DATE] failed to indicate a Brief Interview for Mental Status (BIMS) score. A review of Resident #63's care plan initiated [DATE] indicated that Resident #63 makes his/her own health decisions. A review of Resident #63's [DATE] physician's orders indicated the following: -Incision right hip. Start date [DATE]. -Wound vacuum settings 125 mmhhg (milliliters of mercury), change Monday-Wednesday-Friday. Start date [DATE]. -Cefazolin Sodium injection solution, use 2 grams intravenously every 8 hours for surgical incision until [DATE]. Start date [DATE]. On [DATE] at 8:46 A.M., the surveyor observed Resident #63 in bed. [...]

Inspectors wroteBased on record review and interview the facility failed to implement an Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics.

Inspectors wroteBased on interviews and review of the Facility Assessment, the facility failed to designate one or more individuals as the infection preventionist who are responsible for the facility's infection prevention and control plan. Specifically, the facility failed to have a qualified infection preventionist with completed specialized training in infection prevention and control.

Inspectors wrote3. For Resident #60 the facility failed to ensure accuracy of the MDS related to documentation from the physician that a gradual dose reduction of administered antipsychotic medication was documented as clinically contraindicated. Resident #60 was admitted to the facility in November 2023 and has diagnoses that include but are not limited to unspecified dementia, encephalopathy, and bipolar disorder. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated a staff assessment of mental status indicated Resident #60 as having severe cognitive impairment, and he/she is dependent on staff for self-care including toileting, bathing and dressing. Review of the MDS dated [DATE] indicated under Section N, High-Risk Drug classes that Resident #60 is taking antipsychotic medication, the physician documented a GDR (gradual dose reduction) as clinically contraindicated. [...]

Inspectors wrote2b. For Resident #9 the facility failed to ensure skin assessments were implemented in accordance with the medical plan of care. Resident #9 was admitted to the facility in August 2012 and has diagnoses that include but are not limited to metabolic encephalopathy, bipolar disorder, moderate protein malnutrition, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #9 scored a 7 out of 15 on the Brief Interview for Mental Stats exam which indicated he/she as having severe cognitive impairment, requires partial/moderate assistance for self-care activities including bathing and dressing. Further review of the MDS indicated Resident #9 is at risk for developing pressure ulcers/injuries. Review of Resident #9's medical record indicated a Norton Scale for Predicting Risk of Pressure Ulcers, dated 10/22/24 as high risk. [...]

Inspectors wroteBased on observations, and interviews, the facility failed to ensure medications were stored in locked compartments on one nursing unit.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that the Quality Assurance Committee developed and implemented an effective Performance Improvement Plan (PIP), including a corrective action plan with effective monitoring for Pressure ulcers, infection control surveillance plan, adequate Nursing staffing, and annual wound competencies. [...]

Inspectors wroteBased on record review and interviews, the facility failed to offer the COVID-19 (Coronavirus disease) vaccine to three out of a sample of five employees. Specifically, the facility failed to offer COVID-19 vaccinations during the new hire orientation.

Inspectors wroteBased on document review and interview, the facility failed to maintain records of Certified Nurse Aide (CNA) trainings for continuing competency that included no less than 12 hours of mandatory trainings per year for each CNA employed by the facility for two out of five CNAs reviewed.

Inspectors wroteBased on record review and interview, the facility failed to notify the physician of a refusal of a medication for one Resident (#55), out of a total sample of 24 residents. Specifically, the facility failed to notify the physician of Resident #55's refusals of his/her ordered furosemide (a medication that removes fluid).

Inspectors wroteBased on interviews and record review, the facility failed to develop a baseline care plan within 48 hours of the resident's admission for one Resident #224 out of a sample of 24 residents. Specifically, (i) the facility failed to develop a substance use history base-line care plan, (ii) a suicide attempt history base-line care plan within 48 hours of the resident's admission.

Inspectors wroteBased on record review and interviews, the facility failed to develop a comprehensive person-centered care plan for one Resident (#24) out of a total sample of 24 Residents. Specifically, the facility failed to develop a plan of care after Resident #24 developed pressure ulcers to his/her back.

Inspectors wroteBased on observation, record review and interviews, the facility failed to provide the necessary care and services related to showers for one resident (#37), in a total sample of 24 residents.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#55) out of sample of 24 residents. Specifically, the facility failed to include a physician's order for the use of oxygen in the medical record.

Inspectors wroteBased on record review and interview, the facility failed to ensure physician visits were completed as required upon admission for two residents (#50 and #66) out of a total of 24 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to provide behavioral health services for one Resident, (#68) out of a total of 24 sampled Residents. Specifically, the facility failed to ensure ongoing psychotherapy/talk therapy was provided for Resident #68 and failed to develop and implement a care plan related to Resident #68's diagnosis of depression and anxiety.

Inspectors wroteBased on record review and interview the facility failed to ensure for one Resident (#13), out of 5 applicable residents, out of a total sample of 24 residents, that monthly pharmacy medication regimen review recommendations were implemented in accordance with the physician/nurse practitioner response to the recommendations.

Inspectors wroteBased on record review and interviews, the facility failed to issue a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) (a form issued by SNFs to notify Medicare beneficiaries of potential financial liability for certain services) for 2 out of a sample of 3 residents. Specifically, the facility failed to issue SNF ABN notices after skilled services ended.

Inspectors wroteBased on observations and interviews, the facility failed to post nursing staff data daily, at the start of each shift, as required. Specifically, the facility failed to ensure they consistently posted the staffing as required.

Inspectors wroteBased on records reviewed, interviews and observation for one of two resident care units, the Facility failed to ensure the food/beverage items served to the residents were safe and at an appetizing temperature.

Inspectors wroteBased on observations, interviews and record review, for two of two Nourishment Kitchenettes (Main 1 and Main 2), the Facility failed to ensure that food items prepared and served to residents were done safely, securely, were properly labeled and had not expired.

Inspectors wroteBased on records reviewed and interviews for one of three sampled Residents (Resident #2), the Facility failed to ensure they maintained a complete and accurate Medical Record, when on 04/09/25 there was no Nursing documentation related to his/her acute Hospital transfer or return to the Facility.

Inspectors wroteBased on record review and interviews, for three of three sampled Employee Personnel Files (Nurse #1, Nurse #4, and Certified Nurse Aide #3), the Facility failed to ensure they completed and followed abuse prohibition procedures as defined in their policy when Massachusetts Nurse Aide Registry background checks were not conducted prior to hire.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide a safe environment free from abuse for one Resident (#41) out of a sample of 24 residents. Specifically, the facility failed to provide an environment free from physical, sexual and mental abuse.

Inspectors wroteBased on observations, interviews and record review, the facility failed to implement their abuse policy for one Resident (#41) out of a sample of 24 residents. Specifically, 1. The Director of Nurses (DON) and Assistant Director of Nurses (ADON) failed to notify the Administrator about allegations of physical, sexual and mental abuse, 2. Keep Resident #41 safe by suspending the staff member involved in the abuse allegations, 3. Failed to report and investigate the abuse allegations as required, and 4. Failed to report the allegations to the state agency (SA) and law enforcement.

Inspectors wroteBased on observations, interviews and record review, the facility failed to report an allegation of abuse for one Resident (#41) out of a sample of 24 residents. Specifically, the facility failed to report allegations of physical abuse, sexual abuse and mental abuse to the (SA) state agency.

Inspectors wroteBased on observations, interviews and record review, the facility failed to investigate allegations of abuse for one Resident (#41) out of a sample of 24 residents. Specifically, the facility failed to investigate allegations of physical, sexual and mental abuse.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that nursing staff implemented standards of practice by failing to do the controlled substance count (a control measure to safeguard and maintain accurate dispensing and inventory of controlled substances), at the time of a change in shift, on one of two resident care units.

Inspectors wroteBased on observation, menu review and interview the facility failed to ensure meals provided to residents on two of two resident care units for two of two meals tested, were palatable, attractive and at appetizing temperatures.

Inspectors wroteBased on record review and interview, the facility failed to implement their Quality Assurance Performance Improvement plan during a transition of leadership to ensure practices to support quality of care were implemented. Specifically, the facility failed to identify, and develop a plan for services provided by Registered Nurses and failed to identify and develop a plan to ensure the Director of Nursing was not working as a charge nurse.

Inspectors wroteBased on interview and policy review, the facility failed to maintain an infection prevention and control program designed to help prevent the potential transmission of communicable diseases and infections within the facility. Specifically the facility failed to 1. track and trend infections in the facility and 2. failed to ensure a water management program was implemented to minimize the risk of Legionella and other opportunistic pathogens in building water systems by having a documented water management program.

Inspectors wroteBased on record review, policy review and interview, the facility failed to implement their Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics.

Inspectors wroteBased on record review and interviews, the facility failed to maintain professional standards of nursing practice for four Residents, (#63, #69, #27 and #54) out of a sample of 24 residents. Specifically: For Residents #63, Resident #69 and Resident #27, the records failed to indicate that medications were administered as ordered. For Resident #54, the facility failed to follow physician's orders to re-evaluate a temporarily invoked health care proxy.

Inspectors wroteBased on record review and interview, the facility failed to ensure sufficient staffing levels were maintained to provide resident care on two of two units.

Inspectors wroteBased on record review and interview, the facility failed to ensure staffing included the services of a Registered Nurse for a minimum of eight consecutive hours a day, seven days a week as required and failed to ensure the Director of Nursing did not act as a charge nurse.

Inspectors wroteBased on record review and interview, the facility failed to ensure recommendations from the Monthly Medication Review conducted by the pharmacist were addressed and acknowledged by the physician in a timely manner for three Residents (#34, #59 and #46) out of a total sample of 24 Residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident issues brought forth to staff during the Resident Council Meeting were responded to and a resolution provided.

Inspectors wroteBased on record review and interview the facility failed to accurately complete the Minimum Data Set Assessment for two Residents (#42 and #71) out of a total sample of 24 residents.

Inspectors wroteBased on interviews and records reviewed, the facility failed to develop care plans for one Resident (#27) out of a sample of 24 residents. Specifically, the facility failed to develop care plans related to a history of suicidal ideations and a history of alcohol abuse.

Inspectors wroteBased on record review and interview, the facility failed to ensure hearing services were provided for one Resident (#4) out of a total of 24 sampled Residents.

Inspectors wroteBased on observation, record review and interview for one Resident (#38), out of a total sample of 24 residents, the facility failed to ensure risk assessments and skin evaluations were implemented for the prevention for developing pressure ulcer/injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided appropriate care and services for one Resident (#40) with a Gastrostomy tube (G-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medications), out of 24 sampled residents. Specifically, the facility failed to ensure staff labeled the enteral formula bag and water flush bag with the Resident's name, the formula used, the administration rate, duration, and initials of the staff member hanging them.

Inspectors wroteBased on record review, policy review and interviews, the facility failed to ensure psychotropic medications were re-evaluated after 14 days of use for two Residents (#34 and #46) out of a total sample of 24 Residents.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure it was free from a medication error rate of greater than 5% when two out of three nurses observed made 2 errors out of 30 opportunities resulting in a medication error rate of 6.67 %. Those errors impacted two Residents (#39 and #37), out of 5 residents observed.

Inspectors wroteBased on observation, policy review and interview the facility failed to 1. ensure medications and biologicals were stored in a safe and secure manner in one of two medication carts, 2. failed to ensure medications were properly labeled in two of two medication carts observed, and 3. failed to ensure medication carts were locked when unattended.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide dental services for one Resident (#71) out of a total of 24 residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to: 1. store food under sanitary conditions and 2. failed to prevent cross contamination evidenced by staff not performing hand hygiene before donning and doffing gloves.