Maplewood Health Care Center

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to maintain and ensure the prevention and spread of infection when staff failed to use Personal Protective Equipment (PPE) during dining and medication administration for 3 of 8 (Resident #7, #47, and #114) sampled residents reviewed.

Inspectors wroteBased on policy review, facility daily staffing review, medical record review, hospital record review, and interview, the facility failed to ensure residents were free of neglect as evidenced by the facility's failure to provide sufficient licensed nursing staff to perform assessments and administer morning medications as ordered for 6 of 6 (Resident #1,#2, #3, #4, #5, and #6) sampled residents reviewed. The facility's failure resulted in Immediate Jeopardy (IJ) when Resident #1 experienced a change of condition, and a nurse was not available on the 100 Hall to assess Resident #1. Resident #1's spouse called 911. Resident #1 was evaluated in the Emergency Department (ED) and admitted to the hospital. [...]

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to provide care and services to prevent the development of a pressure ulcer/injury and failed to provide treatments for 2 of 4 (Residents #72, and #85) sampled residents reviewed for pressure ulcers/injuries. Resident #72, who was at risk of developing pressure ulcers/injuries due to contractures [a permanent tightening of muscles, tendons, ligaments, skin, or other tissues that limits movement of a joint or body part] of the extremities and was dependent on staff for preventative interventions, developed a pressure ulcer/injury to the palm of her left hand from having long fingernails embedded into the skin, resulting in actual Harm to Resident #72.

Inspectors wroteBased on policy review, medical record review, facility investigation review, and interview, the facility failed to implement fall interventions for 1 of 4 (Resident #56) sampled residents reviewed for falls. The facility failed to follow the fall prevention intervention of 2 person bed mobility assistance, when on 11/17/2024, Resident #56 fell out of the bed and sustained a fractured hip, resulting in Actual HARM to Resident #56.

Inspectors wroteBased on policy review, observation, kitchen sanitation logs, and interview, the facility failed to ensure food was stored, handled, prepared, and served under sanitary conditions. The kitchen floor was dirty, the cook ware had sticky black carbon build-up, the convection oven had dried food particles inside with thick black sticky substance buildup. The meal and miscellaneous carts were dirty with dry food particles inside the carts. The facility failed to complete the food temperature log, freezer log, and cooler log. The facility failed to check the dish washer temperatures and sanitizing solution level three times a day. The facility had a census of 103 with 101 of those residents receiving a tray from the kitchen.

Inspectors wroteBased on policy review, observation, and interview the facility failed to provide a private space that prevented interference for the resident group meeting for 1 of 1 (Resident Council) sampled group reviewed.

Inspectors wroteBased on policy review, observation, and interview the facility failed to provide a private space that prevented interference for the resident group meeting for 1 of 1 (Resident Council) sampled group reviewed.

Inspectors wroteBased on policy review, medical record review and interview, the facility failed to notify the resident's legal representative of a transfer of the resident from the facility for 1 of 1 (Resident #81) sampled resident reviewed for notification of change.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to provide effective housekeeping to maintain a sanitary environment for 4 of 86 resident rooms (Residents #3, #28, #34, #61, #82, #84, and #94)

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to report an allegation of staff to resident abuse for (Resident #76 and #307) and an injury of unknown origin (Resident #81) for 3 of 10 sampled residents reviewed for Abuse.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to thoroughly investigate alleged allegations of abuse that included an injury of unknown origin (Resident #81) and staff to resident abuse (Resident #307) for 2 of 11 sampled residents reviewed for abuse.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to develop a care plan for 1 of 32 (Resident #72) residents reviewed for care plans.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to conduct a quarterly care plan conference meetings with resident/family representative for 1 of 32 (Resident #68) sampled residents reviewed for care plan meetings.

Inspectors wroteBased on facility policy review, observation, and interview the facility failed to ensure that medication records were in order and an account of the controlled medications were maintained and reconciled for 1 of 5 Registered Nurse (RN) J observed for Medication Administration.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure medications were properly stored and labeled when expired medications were observed in 1 of 1 (Med Storage Room) medication storage areas, and when an over-the-counter medication was observed in a shared bathroom.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infections for 1 of 1 (Licensed Practical Nurse (LPN) E) staff members that failed to use hand hygiene during ostomy care.

Inspectors wroteBased on review of the National Pressure Ulcer Advisory Panel (NPUAP) Prevention and Treatment of Pressure Ulcers: Quick Reference Guide, policy review, medical record review, observation, and interview, the facility failed to ensure the Responsible Party was notified of a newly identified pressure ulcer, failed to ensure the Wound Care Nurse was notified of skin condition changes, and failed to ensure the Physician was notified and orders were obtained for a newly identified pressure ulcer for 1 of 5 sampled residents (Resident #42) reviewed with in-house acquired pressure ulcers. The facility's failure to notify the Wound Care Nurse of skin condition changes/redness and to notify the Physician and obtain orders for a newly identified pressure ulcer resulted in actual Harm when skin condition changes deteriorated and progressed to an Unstageable pressure ulcer.

Inspectors wroteBased on review of the National Pressure Ulcer Advisory Panel (NPUAP) Prevention and Treatment of Pressure Ulcers: Quick Reference Guide, policy review, medical record review, observation, and interview, the facility failed to ensure changes in a resident's skin condition were identified, assessed, reported, a physician's order for treatment was obtained and treatments were provided before the skin condition changes deteriorated to an Unstageable Pressure Ulcer and failed to ensure a pressure ulcer was accurately assessed and identified before it became an unstageable pressure ulcer for 2 of 5 sampled residents (Resident #42 and #99) reviewed with in-house acquired pressure ulcers. [...]

Inspectors wroteBased on the Centers for Disease Control and Prevention (CDC) guidelines, policy review, review of Employee Screening logs, employee time sheets, observation, and interview, the facility failed to ensure practices to maintain the spread of infection were maintained when 11 of 144 staff members (Agency Licensed Practical Nurse (LPN) #2, #3, #4, #5 and #6, Certified Nursing Assistant (CNA) #1, #3, and #4, Agency CNA #1, #2, and #3) failed to complete screening for the prevention and detection of COVID-19 prior to working on 3 of 3 days (8/12/2022, 8/13/2022, and 8/14/2022) reviewed, when 2 of 5 nurses (Agency LPN #1 and LPN #2) failed to discard a lancet in the sharps container and failed to clean the inhaler mouth piece after use, and when 1 of 1 CNA (Restorative CNA #1) failed to clean the reusable equipment (resident lift) after use. [...]

Inspectors wroteBased on policy review, observation, and interview, the facility failed to maintain or enhance residents' dignity and respect when staff failed to provide privacy for 3 of 7 sampled residents (Resident #54, #57 and #91) reviewed during medication administration and when an indwelling urinary catheter was uncovered and visible to hallway traffic for 1 of 2 sampled residents (Resident #99) reviewed for urinary catheters.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored and secured when medications were found unattended and unsecured in 2 of 84 resident rooms (Resident #2 and #28's room), when 1 of 7 medication carts (100 Hall Extended Medication Cart) was left unlocked and unattended, when opened, unlabeled and expired medications were found in 4 of 7 medication carts (100 Extended Hall Medication Cart, 200 Hall Medication Cart, 300 Hall Medication Cart, and 400 Hall Medication Cart), and when a medication was hanging out of the medication cart and was unsecured on 1 of 7 medication carts (100 Extended Hall Medication Cart).

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to conduct Care Plan meetings and include the Interdisciplinary Team (IDT) for 5 of 29 sampled residents (Resident #16, #32, #35, #94 and #99) reviewed for care planning.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to provide an ongoing program of activities designed to meet the interests, physical, mental, and psychosocial well-being for 1 of 1 sampled resident (Resident #99) reviewed for activities.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure the environment was free of accident hazards when 1 of 3 sampled residents (Resident #35) reviewed for accident hazards was observed smoking without wearing a smoking apron.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to obtain and follow Physician Orders for oxygen for 2 of 4 sampled residents (Resident #65 and #66) reviewed for respiratory care.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure sufficient staffing for 1 of 5 sampled residents (Resident #42) reviewed for Pressure Ulcers.