Maplewood Nursing and Rehab Center

Inspectors wroteBased on review of facility policy, staff interviews, resident interviews, and observations it was determined that the facility did not ensure a resident was free from exploitation for one of nine residents reviewed. (Resident R3)Findings Include: Review of facility policy titled, Abuse last revised October 24, 2022 states, Definitions of Abuse and Neglect- Abuse and neglect exist in many forms and to varying degrees. The following are the approved CMS definitions of abuse and neglect from the Draft State Operations Manual Appendix PP effective November 28, 2016. Further review of the policy states, a. Mistreatment means inappropriate treatment or exploitation of a resident. Review of Resident R3's clinical record revealed the resident was admitted to the facility on [DATE] with the following diagnosis: [...]

Inspectors wroteBased on observations, interviews, review of facility policy, and review of facility documentation it was determined that the facility did not ensure to report the results of all investigations to state officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and did not have evidence that all alleged violations were thoroughly investigated for two of ten residents reviewed. (Resident R1 and Resident R2)Findings Include: Review of facility policy titled, Smoking Safety Policy last revised October 22, 2022 states, Policy- it is the facility policy to provide a safe environment for our residents, staff and visitors by defining and enforcing safe smoking practices. [...]

Inspectors wroteBased on observations, clinical record review, resident interviews, and staff interviews, it was determined that the facility did not ensure residents were free from foreseeable accidents and hazards related to smoking for four of ten residents reviewed. (Resident R1, R2, R4, R5)Findings Include: Review of facility policy titled, Smoking Safety Policy last revised April 7, 2026 states, It is the facility policy to provide a safe environment for our residents, staff and visitors by defining and enforcing safe smoking practices. Residents who smoke will be permitted to smoke in the designated outside smoking area. They must agree to and comply with the safe smoking practices and the conditions of the Smoking Safety Policy and Procedure. [...]

Inspectors wroteBased on record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure medications were delivered by a licensed nurse, who has the skills, experience and knowledge to administer medications for one of four residents reviewed (Resident R1). Findings Include: Review of Facility's medication administration policy revealed only persons licensed or permitted by this state to prepare, administer and document the administration of medication may do so. Review of the facility grievance log revealed Resident R1 reported a concern on February 23, 2026. Resident R1 stated that Licensed nurse, Employee E4 did not give (him/her) medications. Continued review of the grievance revealed that Licensed nurse, Employee E4 stated Resident R1 will not accept medication from (her/him). [...]

Inspectors wroteBased on staff and resident interviews and review of clinical records, it was determined that the facility failed to ensure that documented room change notifications to the resident and/or emergency contact were provided for one out of 33 residents reviewed (Resident R133).

Inspectors wroteBased on review of facility policies and clinical records and staff interviews, it was determined that the facility failed to ensure that a written summary of the baseline care plan was provided to the resident and/or the resident's representative for one of two residents reviewed (Resident R151).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to update resident's physician orders related to dialysis schedule for one of one resident review receiving hemodialysis treatment (Resident R8). Findings Include: Review of the medical record revealed that Resident R8 was admitted on [DATE], with diagnosis including, but not limited to end stage renal disease (the final stage of chronic kidney disease, where kidneys can no longer function adequately, requiring dialysis or a kidney transplant for survival). Further review of the clinical record for Resident R8 revealed a July 25, 2025, physician's order for hemo dialysis at a local dialysis center with a 10:00 a.m. chair time every Monday, Wednesday and Friday. Interview with the Unit Clerk, Employee E7 on the second floor on August 28, 2025, at 9:30 a.m. [...]

Inspectors wroteBased on review of clinical records, staff and resident interviews, it was determined that the facility failed to provide culturally competent, trauma care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident for one of four residents sampled for post-traumatic stress disorder(PTSD) care for one of 33 residents reviewed. (Resident R4).

Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to offer and/or provide the influenza and pneumococcal immunization for three of five residents reviewed (Resident R43, R55 and R151).

Inspectors wroteBased on review a facility policy, review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to ensure that a resident was safely transfer via mechanical lift for one of four residents reviewed. (Resident R1)

Inspectors wroteBased on review of facility provided documentation, interview with staff and review of clinical record, it was determined that facility failed to ensure that require information to obtain an imaging study was submitted for one out of nine residents reviewed. (Resident R4)

Inspectors wroteBased on observations, review of facility policies and interviews with staff, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Inspectors wroteBased on observations, review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to develop comprehensive person-centered care plans, related to behaviors, nutrition and contractures, for four of 32 residents reviewed (Residents R129, R100, R117 and R38).

Inspectors wroteBased on observations, review of facility policies and interviews with staff, it was determined that the facility failed to maintain effective infection control practices related to barrier precautions and personal protective equipment for three of 32 residents reviewed (Residents R43, R81, and R52) and proper disposal of PPE by staff prior to leaving room for 4 out of 17 rooms observed.

Inspectors wroteBased on clinical record reviews, review of facility policies, and staff interviews, it was determined that the PASRR (Preadmission Screen and Resident Review) was not appropriately revised according to the resident assessment for one of three residents reviewed. (Resident R77)

Inspectors wroteBased on observations, clinical records reviews, it was determined that the facility failed to develop a baseline care plan within 48 hours of admission that includes the instructions needed to provide effective and person-centered care, ADL (activity of daily living) needs for one of 32 residents reviewed (Resident R362).

Inspectors wroteBased on observations, review of clinical records, and staff and resident interviews, it was determined that the facility failed to ensure residents with limited range of motion received treatment and services to maintain or improve range of motion/mobility for one of five residents reviewed with limited range of motion (Resident R38). Findings Include: Review of Resident R38's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated September 16, 2024, revealed the resident was cognitively intact and had diagnoses of hemiplegia (paralysis of one side of the body), muscle wasting, and muscle weakness. Further review of Resident R38's quarterly MDS dated [DATE], revealed the resident had impairment in range of motion on one side of the upper extremity. Observations on November 3, 2024, at 12:50 p.m. [...]

Inspectors wroteBased on review of clinical records, review of facility policy and staff interview, it was determined that the facility failed to ensure communication with the dialysis provider for one of two residents reviewed on renal dialysis (Resident R22)

Inspectors wroteBased on observations, review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure a medication error rate of less than five percent for two of four residents observed during medication administration (Residents R43 and R108).

Inspectors wroteBased on observations, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that medications were properly labeled and dated for two of three medication carts reviewed (fourth floor A and B carts), and failed to ensure that a medication cart was kept locked when not in use during medication administration for one of three nursing units observed (third floor nursing unit).

Inspectors wroteBased on review of personnel files, review of facility documentation, and staff interviews, it was determined that the facility failed to employ a qualified Registered Dietitian and Director of Food and Nutrition Services. Findings Include: Review of the job description for the Director of Food and Nutrition Services revealed that job responsibilities included oversight of ordering, receiving, storing, preparation and service of food. Interview on November 4, 2024, at 11:45 a.m. with Registered Dietitian, Employee E8, confirmed the Registered Dietitian only worked at the facility part time. Review of Food Service Directors, Employee E4, personnel file revealed the employee held the position of Dietary Director with a start date of July 17, 2023. Review of the Food Service Directors, Employee E4, personnel file confirmed the employee was not currently a certified dietary manager (CDM); [...]

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to employ sufficient dietary personnel to carry out the functions of the food and nutrition service for one of one meal observed (Breakfast November 3, 2024). Findings Include: Observation on November 3, 2024, revealed that the posted mealtimes on the fourth-floor nursing unit were: Breakfast 7:40 a.m. to 8:40 a.m. Observations in the main kitchen on November 3, 2024, at 9:00 a.m. revealed dietary staff were preparing for the breakfast meal service and cooking food. Observations revealed there was one dietary personnel cooking the breakfast and three dietary aides preparing the resident beverages and meal trays for service. Interview on November 3, 2024, at 9:00 a.m. with the Assistant Food Service Director, Employee E24, revealed the cook did not show for the breakfast shift. [...]

Inspectors wroteBased on observations, review of facility documentation, and staff and resident interviews, it was determined that the facility failed to ensure menus were followed for three of three nursing units observed (second, third and fourth floor nursing units).

Inspectors wroteBased on observations and interviews with residents and staff, it was determined that the facility failed to ensure that food was palatable and served at appetizing temperatures.

Inspectors wroteBased on observations, review of facility documentation, and staff interviews, it was determined that the facility failed to prepared foods in a form that meet resident needs for 8 of 8 residents on a pureed diet (Resident R100, R124, R21, R148, R8, R138, R81, R53). Findings Include: Review of facility diet manual signed by the Medical Director on January 1, 2023, and signed by the Food Service Director on September 1, 2023, revealed the facility follows the International Dysphagia Diet Standardization Initiative (IDDSI - provides a common terminology to describe food textures and drink thickness) Framework for food and beverage consistencies. Continued review of the facility diet manual revealed IDDSI Level 4 -Pureed Diet are foods pureed which are of a smooth, homogenous, and cohesive consistency and keep their shape when on a spoon. [...]

Inspectors wroteBased on observations, review of clinical record, and staff interview, it was determined that the facility failed to provide beverages consistent with resident needs for two of twenty-seven residents reviewed for dining (Resident R152 and R145).

Inspectors wroteBased on observations, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to ensure that meals were served timely on three of three nursing units observed (second, third and fourth floor nursing units) and failed to ensure that residents were provided snacks for two of 32 residents reviewed (Residents R68 and R34)

Inspectors wroteBased on review of facility documentation, review of clinical records, and staff interview, it was determined that the facility failed to submit complete records related to rehabilitation services for three of 32 residents reviewed (Resident R110, R113, R38).

Inspectors wroteBased on a review of facility documents and resident clinical records and interviews with staff, it was determined that the facility failed to ensure that residents had the capacity to understand the terms of a binding arbitration agreement for one of nine residents reviewed (Resident R259).

Inspectors wroteBased on observations and interviews with residents and staff, it was determined that the facility failed to ensure that essential dining equipment in the kitchen and essential resident equipment was maintained in proper working order for two of 32 residents reviewed (Residents R26 and R38).

Inspectors wroteBased on observation of the facility's physical environment and interviews with staff, it was determined that the facility failed to ensure that a supply of potable (safe for drinking) water on hand at the facility in the event that there was a loss of normal water supply. Findings Include: Interview on November 6, 2024, at 11:15 a.m. with the Food Service Director, Employee E4, revealed based on a census of 156 residents, the facility should have 3-gallons of water per resident for emergency purposes. Further interview revealed based on the above information the facility should have a total of 468 gallons of emergency water. Observations of the emergency water storage on November 6, 2024, at 11:30 a.m. with the Food Service Director, Employee E4, revealed the facility only had 294 gallons of emergency water on hand. [...]

Inspectors wroteBased on observations, review of facility documentation and interviews with staff, it was determined that the facility failed to maintain an effective pest control program in the kitchen and for two of 32 residents reviewed (Resident R81 and R309).

Inspectors wroteBased on observations, review of facility menus and interviews with residents and staff, it was determined that the facility failed to ensure that menus were posted and followed as required on one of four floors observed (third floor).

Inspectors wroteBased on review of facility policy, review of facility documentation, review of clinical records, and interviews with residents and staff, it was determined that the facility failed to ensure that the resident environment remained free of accident hazards by failing to monitor the temperature of hot water beverages served to a resident. This failure resulted in actual harm to Resident R1 who spilled a hot water beverage and sustained an abdominal and chest burn injury, for one of five residents reviewed. (Resident R1)

Inspectors wroteBased on observations, clinical record review, review of facility policy and interviews with residents and staff, it was determined that the facility failed to provide assistance with showers for one of eight residents reviewed (Residents R4).

Inspectors wroteBased on observation, review of facility policies, facility documentation and interviews with staff, it was determined that the facility failed to ensure that water temperatures in resident bathroom hand sinks and shower rooms were maintained at a safe temperature for three of three nursing units (Second, Third and Fourth Floor Nursing Units). This failure placed residents on the (Second, Third and Fourth Floor Nursing Units) at risk for serious injury from a burn and resulted in an Immediate Jeopardy situation. (Second, Third and Fourth Floor Nursing Units). Findings Include: [...]

Inspectors wroteBased on observation, a review of facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility related to hot water temperatures in three of three nursing units (Second, Third and Fourth floor) which resulted in an immediate jeopardy situation. Findings Include: Review of the job description for the Nursing Home Administrator (NHA) revealed the Nursing Home Administrator (NHA) assumes full-time administrative authority, responsibility and accountability for the operations and for the financial viability of the nursing facility. Manages facility employees in the provision of care and services rendered in accord with professional standards, and in compliance with state and federal laws and regulations. [...]

Inspectors wroteBased on observations of the operations of the Food and Nutrition Services Department and interviews with staff, it was determined that foods were not being stored, prepared, distributed and served in accordance with professional standards for food service safety.

Inspectors wroteBased on observations of care and services, reviews of policies and procedures, interviews with residents, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that each resident's needs and preferences were reasonably accommodated to create an individualized home-like environment for one of six residents reviewed. (Resident R143).

Inspectors wroteBased on observations of care and services, clinical record reviews, interviews with staff and reviews of policies and procedures, it was determined that the facility failed to implement a plan of care to address the dementia needs of one of 32 residents reviewed. (Resident R96 )

Inspectors wroteBased on observation, and review of clinical records, it was determined that the faciltiy failed to ensure that range of motion exercises were inititated and that the use of a sit and stand lift was maintained for one of two residents reviewed (Resident R70)

Inspectors wroteBased on observations, review of facility policy, interviews with staff, and review of facility documentation, it was determined the facility failed to ensure that weights were monitored for three of 32 residents reviewed (R36, R97, R106) Findings Include: Review of Weight Assessment and Intervention Policy dated February 15, 2020 states, The nursing staff and the Dietician will cooperate to prevent, monitor, and intervene for undesirable weight loss for our residents. Further review of the facility policy states, 4. The Dietician will also review monthly weights to follow individual weight trends over time. Negative trends will be assessed and addressed by the Dietician whether or not the definition of Significant Weight Change is met. Review of Resident R36's Minimum Data Set(MDS- assessment of resident's care needs) revealed an admission date of February 22, 2021. [...]

Inspectors wroteBased on observations, clinical record review and resident interview, it was determined that routine dental care was not provided for one of six residents reviewed with dental, chewing and swallowing needs. (Resident R121)

Inspectors wroteBased on observation, interviews with staff and review of facility policy and procedure, it was determined that the facility did not maintain an effective infection control program related to hand hygiene and medication administration for one resident (Resident R53) of four residents observed and glucometer handling and testing for one resident (Resident R19) of one resident observed.

Inspectors wroteBased on observations, interviews with staff and residents and review of facility policy, it was determined that the facility failed to ensure that call bells were with in reach for 17 of 24 residents reviewed. (Resident R1, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, and R24).