Maplewood Healthcare Center

Inspectors wroteBased on observation, staff interview, resident interview, and record review, the facility failed to ensure residents received the portions specified on the facility's approved production sheets and failed to consistently provide menu items as planned. This deficient practice had the potential to affect all residents receiving meals from the facility's dietary department. Facility census: 76Findings include: During an observation of the lunch tray line on 06/10/26 beginning at approximately 12:30 p.m., [NAME] #94 was observed serving roasted squash. The facility's serving utensil was a four (4) ounce scoop; however, the scoop was not filled to capacity. The scoop was frequently less than half full and at times only approximately half full before being placed on resident trays. [...]

Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to ensure resident grievances were appropriately tracked, resolved, and reviewed by the designated grievance official/administrator. Additionally, the facility failed to ensure grievance documentation was completed, including administrator review and signature. This deficient practice affected Resident #74 and had the potential to affect more than a minimal number of residents residing in the facility. Facility census: 76.

Inspectors wroteBased on facility documentation and staff interviews, the facility failed to have/keep the required documentation for Quality Assessment meetings (QAA). Additionally, the facility did not have required attendees present or sign in at the Quality Assessment and Assurance (QAA) meeting logs. This failed practice had the potential to affect all residents residing at the facility. Facility Census: 76.

Inspectors wroteBased on Interview and Record review the facility did not evidence of the required attendees being present or having them sign in to verify their presence at the Quality Assessment and Assurance (QAA) meeting. This was discovered during the regular survey process and has the ability to effect more then a limited number of residents. Census 76. During an interview with both the Director of Nursing (DON) and Regional Director Clinical Operations (RDCO) on 01/14/2026 at approximately 8:50 AM, both stated they have been looking for the Quality Assurance (QAPI/QAA) books or records since the survey team entered the facility. Unfortunately, they were unable to locate documentation to show their meetings and what was discussed. They provided the names of the active participants from the meetings, but only a few sign in sheets had been found. [...]

Inspectors wroteBased on observation, medical record review, and staff interview the facility failed to establish and maintain an infection prevention program to help prevent the development and transmission of communicable diseases and infections including Covid-19 in regard to, precaution signage on resident doors. This had the potential to affect all residents that reside in the facility. Resident identifiers: #60 and #62. Facility Census: 76. a) Observations on 01/06/26 at 1:13 PM revealed no signs near the door frames of room B2. Interview on 01/06/26 at 1:13 PM with Nurse Aid #38 she verified that both residents in room B2 were on isolation precautions. Continues review revealed Resident # 60's clinical record revealed that theresident was diagnosed with Covid-19 on 01/02/26 and was placed on precautions. [...]

Inspectors wroteBased on record review, resident interview, staff interview and Operation Policy review the facility failed to ensure they implemented the facility written abuse policy in regard to investigating and reporting to proper agencies an alleged allegation of abuse or neglect. This has potential to affect all residents that reside at the facility. Resident identifier: #47 and #9. Facility census: 76.

Inspectors wroteBased on observation, staff interview, and operation policy the facility failed to report alleged violations related to, neglect, or abuse, and report the results of all investigation to the proper authorities within prescribe time frames. This was a random opportunity for discovery. Resident identifier: #9 and #47. Facility census: 76.

Inspectors wroteBased on resident interview, staff interview, and operation policy, the facility failed to report the results of an investigation to the appropriate officials in accordance with State law, within five (5) working days of the incident. This has the potential to affect all residents in the facility. Resident identifier #9, #47 and #40. Facility census:

Inspectors wroteBased on record review and staff interview the facility failed to implement their abuse prohibition policy in regards to identifying and reporting all allegations of abuse and/or neglect. The facility failed report all allegations of abuse and or neglect to required agencies within the required time frames. This was a random opportunity for discovery and was true for 13 residents for a total of 15 allegations. Resident Identifiers; Resident #4, #50, #54, #16, #60, ##32, #33, #29, #73, #68, #76, #77, and #78. Facility Census: 74. Findings Include: a) Policy Review A review of the facility;s policy Titled: [NAME] Virginia Abuse, neglect, and Misappropriation Policy with an effective date of 10/17/24 found the following: [...]

Inspectors wroteBased on record review and staff interview the facility failed to report all allegations and five (5) day follow up reports of abuse and or neglect to required agencies within the required time frames. This was a random opportunity for discovery and was true for 13 residents for a total of 16 allegations. Resident identifiers: #4, #50, #54, #16, #60, #32, #33, #29, #73, #68, #76, #77, and #78 Facility census: 74.

Inspectors wroteBased on record review, resident interviews, and staff interviews, the facility failed to adequately deploy nursing staff across all shifts to properly care for residents and their safety. This was found to be true for 15 (fifteen) of 15 calendar days. Facility census: 74.

Inspectors wroteBased on record review and staff interview, the facility failed to post nurse staffing with accurate information reflecting the actual hours worked, and total hours worked by category for nursing. This was true for 14 (fourteen) of 15 (fifteen) calendar days reviewed. The facility also failed to accurately reflect Facility census:75

Inspectors wroteBased on record review and staff interview the facility failed to ensure each resident received medically related social services. The facility failed to assist the residents in the assertion of their right related to being free from abuse and or neglect and comprehensive person-centered care planning. This was random opportunity for discovery and has the potential to affect more than a limited number of residents. Resident identifiers: #75, #6, #77, #4, #54, #16, #32, #60, #78, #33, #29, #50, #73, #68, and #16. Facility Census: 74.

Inspectors wroteBased on record review and staff interview, the facility failed to maintain an accurate and complete record for Resident #56. This was true for one (1) of five (5) residents reviewed under the care area of falls. Resident identifier: #56. Facility census: 74. Findings Include: a) Resident #56 On 05/07/25 at 12:30 PM, a record review was completed for Resident #56. The review found the resident had been transferred to an acute care facility. The transfer forms were noted with errors as follows: --Transfer date 11/01/24; incorrect date of 09/06/24 --Transfer date 11/25/24; incorrect date of 11/01/24 --Transfer date 03/04/25; incorrect date of 11/25/24 On 05/07/25 at 1:30 PM, the Administrator was notified and confirmed the dates on the transfer forms were incorrect.

Inspectors wroteBased on record review and staff interview the facility failed to ensure the resident and/or resident representative were afforded the right to participate in the care planning process with all required members of the interdisciplinary team. This was true for two (2) of two (2) sampled residents reviewed during a complaint survey. Resident Identifiers: #6 and #75. Facility Census: 74. Findings Include: a) State Agency Complaint The state agency received a complaint on 11/18/24 which indicated the following: The complainant was contacted by the facility's Social Worker about a care plan meeting for her mom. She said that the social worker normally only contacts her the day before or the day of the meeting but on this occasion, she did contact her a few days prior. This was helpful because she wanted to review her mom's care plan prior to the meeting. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to maintain infection control standards Resident #53's urinary catheter. This was a random opportunity for discovery. Resident identifier: #53. Facility Census: 74.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure a qualified staff person assessed each resident's activity pursuits by not providing a qualified activity professional. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents residing in the facility. Facility census: 76.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the correct alternative menus were posted to be available if the primary menu or immediate selections for a particular meal are not to a resident's liking. This was a random opportunity for discovery, and currently no residents are receiving enteral tube feedings in the facility, therefore; this failed practice had the potential to affect all residents residing in the facility. Facility Census:

Inspectors wroteBased on resident interview and staff interview, the facility failed to review resident rights during the residents stay. This was a random opportunity for discovery during the Long-Term Care Survey process and had the potential to affect more than a limited number of residents in the facility. Facility census: 76. Resident identifiers: #54, #3, #59, #22, #43, #25, #76.

Inspectors wroteBased on staff interview and record review, the facility failed to provide a qualified activity professional for recreational services. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents residing in the facility. Facility Census:

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered food was not stored properly and a treatment mask was found in the supply room. These deficient practices had the potential to affect any resident receiving nourishment from the kitchen. Facility census: 76.

Inspectors wroteBased on observation and staff interviews the facility failed to maintain the garbage storage area in a sanitary condition. It was discovered the dumpster had a trash bag wedged under the dumpster. Facility census: 76.

Inspectors wroteBased on record review and staff interview, the facility failed to notify the resident's representative/family member in a timely fashion of a significant change and the need to alter treatment. The facility transferred Resident #15 and Resident #35 to the hospital. However, their representatives/family members were not notified of the transfer. This was true for two (2) of six (6) residents reviewed for hospitalizations during the Long-Term Care Survey Process. Resident identifiers: #15 and #35. Facility census: 76.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide evidence resident/resident's representative were provided a written Notice of Transfer for an acute hospital transfer. This was true for two (2) out six (6) hospital transfers reviewed during the long-term care process. Resident identifiers: #15, and #35. Facility census: 76.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that the resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses for one (1) of two (2) residents reviewed for the category of PASARR (Pre-admission Screening and Record Review), during the Long-Term Care Survey process. Resident identifiers: #15. Facility census 76.

Inspectors wroteBased on record review and staff interview, the facility failed to revise a resident's person-centered, comprehensive care plan for urinary catheter services. This was true for one (1) of two (2) residents reviewed for urinary catheter care during the Long-Term Care Survey Process. Resident identifier: #37. Facility census: 76.

Inspectors wroteBased on observation and staff interviews the facility failed to provide an environment as free of accident hazards as possible. This was a random opportunity for discovery. Resident identifiers: #48 and #228 Facility census:

Inspectors wroteBased on record review and staff interview, the facility failed to maintain an accurate medical record for one (1) of three (3) records reviewed for accurate POST (Physician Orders for Scope of Treatment) forms during the Long-Term Care Survey process. Resident identifier: #51. Facility census: 76.

Inspectors wroteBased on observation and staff interview the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This was a random opportunity of discovery. Resident Identifiers: #39, #48 and #228. Facility Census: 76 Findings Included: a) Resident #39 On 03/04/24 at 12:33 PM observation was made of Certified Nurse Aid (CNA) #60 passing lunch meal trays on A hall. The CNA passed Resident #39's meal tray without offering the resident any hand hygiene prior to eating her meal. When confirming with the CNA that no hand hygiene was performed and asking if they usually provide hand hygiene she stated, we usually do, you just caught me on an off day, they are up on the meal cart. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure medications were available for administration to residents. This deficient practice had the potential to affect two (2) of three (3) residents reviewed for medications. This deficient practice caused harm to Resident #15. Resident #15 experienced seizures as a result of not receiving anticonvulsant medication as ordered and required an emergency room evaluation and medical testing. Resident identifiers: #15 and #24. Facility census: 76.

Inspectors wroteBased on record review and staff interview, the facility failed to notify the resident's physician, or designee, when there was a need to alter treatment for three (3) of three (3) residents reviewed, when the facility failed to administer medications or failed to obtain laboratory services ordered by the physician. This deficient practice was found to be true for Resident #55 who failed to have laboratory values drawn per physician order , Resident #15 who failed to have laboratory services obtained and failed to receive medication ordered by the physician, and Resident #24 who failed to receive medications ordered by the physician. Resident identifiers: Resident #24, #55, and #15. Census: 76.

Inspectors wroteBased on record review and staff interview, the facility failed to report alleged neglect within the required timeframe. This was a random opportunity for discovery. Resident identifier: #15. Facility census: 76.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the timeliness of laboratory services to meet the needs of their residents. This was found true for two (2) of three (3) residents reviewed in which laboratory services were not obtained in a timely basis for Resident #55 and Resident #15. This deficient practice had the potential to affect more than a limited number of residents residing in the facility. Resident identifiers: Resident #55 and Resident #15. Census: 76.

Inspectors wroteBased on observation and staff interview, the facility failed to display the most recent State inspection survey results in a readily accessible area frequented by residents. It was discovered the State inspection was not posted in an area frequented by residents. This had the potential to affect a limited number of residents. Facility census:

Inspectors wroteBased on record review and staff interview, the facility failed to maintain appropriate standards for completing the Advanced Directives. This was true for one (1) of 20 residents reviewed during the long-term survey process. Resident Identifiers: #52. Facility Census: 75.

Inspectors wroteBased on staff interview and medical record review, the facility failed to develop comprehensive person-centered care plans to meet the psychosocial needs of the residents. Resident (R) #54 and R #6's care plans lack person centered non-pharmacological interventions to assist in dealing with anxiety and depression. This is true for two (2) of five (5) residents reviewed for unnecessary medications. Resident identifiers: R#54 and #6. Facility census: 75.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Splints had not been applied as ordered by the physician. This was true for one (1) of two (2) residents reviewed for the care area of position and mobility. Resident identifier: #22. Facility census: 75.

Inspectors wroteBased on medical record review, respiratory procedure policy, and staff interview the facility failed to provide respiratory services in accordance with professional standards of practice. This was discovered for one (1) of one (1) residents reviewed for respiratory care. Resident identifier: #59 Facility census:

Inspectors wroteThe facility failed to provide pharmaceutical services to meet residents' needs. Resident #71's medications were not received in a timely manner following her admission. This was true for one (1) of two (2) closed record reviews. Resident identifier: #71. Facility census: 75.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Resident #54's as needed anti-anxiety medication was limited to 14 days. This is true for one (1) of five (5) reviewed for unnecessary medications. Resident identifier: #54. Facility census: 75.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles. Expired medications were found in the medication preparation room floor stock. Facility census: 75.

Inspectors wroteBased on observation and staff interview the facility failed to store food in accordance with professional standards for food service safety. During the kitchen tour, food was found not dated after opening. This had the potential to affect a limited number of residents receiving nourishment from the kitchen. Facility census: