Maplewood Rehabilitation Center

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure that care plans were developed and implemented to address the use of blood-thinning medications for 3 of 3 residents (R1, R2 and R3) reviewed. R1 R1's face sheet, printed 1/26/26, identified diagnoses of cerebral vascular accident (stroke) and dysphagia. R1's admission Minimum Data Set (MDS) dated [DATE] identified moderate cognitive impairment, the need for a feeding tube, and receipt of antiplatelet medications. R1's physician's orders dated 1/6/26 identified the resident was to receive clopidogrel 75 mg via G-tube every morning and aspirin 325 mg via J-tube daily with a meal. According to the FDA-approved Plavix (clopidogrel) labeling, clopidogrel is an antiplatelet medication. The FDA-approved labeling warns that Plavix can cause bleeding which can be serious and can sometimes lead to death. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program effectively sustained ongoing compliance related to repeat citations for past surveys regarding provider notification of changes, care plan revisions, arrangement of hearing appointments, oxygen administration, and infection control practices. This had the potential to affect all 101 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure toenail care was completed for 1 of 1 resident (R83) who was dependent on staff assistance for activities of daily living (ADLs).

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure residents received care and services to maintain or prevent decline in range of motion in accordance with their functional maintenance programs for 7 of 7 residents reviewed (R1, R4, R53, R55, R88, R108, and R109). Specifically, the facility failed to implement prescribed range of motion (ROM) exercises as outlined in residents' functional maintenance programs. In addition, the facility lacked a policy or procedure to ensure functional maintenance programs were implemented, communicated to direct care staff, and consistently monitored for completion. This deficient practice resulted in the potential for decreased mobility, increased contractures, pain, and decline in functional status.

Inspectors wroteBased on observation and interview, the facility failed to ensure a resident's right to privacy and dignity was maintained by ensuring personal medical equipment was not exposed to public view for 1 of 1 residents (R88) reviewed for resident rights. Specifically, the facility failed to ensure a urinary catheter drainage bag was positioned discreetly while the resident was laying in his bed with the door opened to the main hallway. This deficient practice had the potential to compromise the resident's dignity and privacy.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure call lights were accessible to 1 of 1 resident (R74) reviewed for call light accessibility.

Inspectors wroteBased in interview and record review the facility failed to ensure notification was made to the provider and resident representative for concerns of toenail infection and refused podiatry appointments for 1 of 1 resident R83 who required podiatry services. Furthermore, the facility failed to promptly notify the resident's physician and/or practitioner of changes in resident condition for 2 of 2 residents (R53 and R55) reviewed for notification of changes. Specifically, the facility failed to notify the provider of episodes of diarrhea for 1 resident (R53) reviewed for constipation and failed to notify the provider of significant weight gain in accordance with physician-ordered parameters for 1 resident (R55). These deficient practices had the potential to delay medical evaluation and treatment.

Inspectors wroteBased on observation and interview, the facility failed to maintain the confidentiality of resident personal and medical information for 1 of 1 resident observed (R98) by allowing resident-identifiable information to be visible on a computer screen located on a medication cart in a public area. This deficient practice resulted in the potential for unauthorized disclosure of protected health information to residents, staff not involved in care, visitors, and others who walked through the area.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean and sanitary environment for 2 of 2 residents reviewed (R55 and R108) by failing to ensure resident room floors were kept clean and free of visible dirt and debris. This deficient practice resulted in the potential for infection transmission, unpleasant living conditions, and compromised resident comfort and dignity.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect anticoagulation status for 1 of 2 residents (R2) reviewed for coding accuracy.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident-centered care plans were developed, implemented, and revised to accurately reflect resident's current needs for 3 of 3 residents reviewed (R55, R102, and R109). Specifically, the facility failed to include required interventions for edema management, failed to update the care plan to remove discontinued enhanced barrier precautions, and contained conflicting information regarding the level of assistance required for eating. These deficient practices resulted in the potential for inconsistent care, unmet resident needs, and compromised resident safety and well-being.

Inspectors wroteBased on observation and interview, the facility failed to ensure activities of daily living (ADLs) related to hygiene and grooming were provided in accordance with resident needs for 1 of 1 residents reviewed (R88) by failing to ensure the resident wore clean clothing throughout the survey period. This deficient practice resulted in the potential for compromised dignity, discomfort, and negative psychosocial impact to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure activities were provided or offered in accordance with resident needs and preferences for 1 of 1 resident reviewed (R109). Specifically, the resident remained in bed for the duration of the survey without activities being offered or provided. This deficient practice resulted in the potential for social isolation, decline in psychosocial well-being, and decreased quality of life.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure audiology appointments were available for 1 of 1 resident (R67) who requested audiology services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure prescribed treatment for urinary tract infection (UTI) prevention was administered or reported as refused for 1 of 2 residents (R47) reviewed for recurring UTIs.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure specific patient centered orders were in place and implemented for colostomy care for 1 of 1 resident (R81) reviewed for colostomy care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care and services were provided in accordance with physician orders and professional standards of practice for 1 of 1 residents reviewed (R109). Specifically, the facility administered oxygen therapy without a physician's order. This deficient practice resulted in the potential for improper oxygen administration, respiratory compromise, and harm to the resident.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain accurately documented medical records for 3 of 3 residents (R47, R68, R83) reviewed who had inaccurate documentation. Findings Include:

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure appropriate infection control measures were in place for maintaining a central line with dressing changes and use of enhanced barrier precautions (EBP) with personal protective equipment (PPE) for 1 of 2 residents (R36) reviewed who had a central line indwelling device.

Inspectors wroteBased on interview and document review, the facility failed to implement individualized interventions to reduce the risk of falls for 1 of 3 residents (R1) reviewed for accidents. This resulted in actual harm for R1 who sustained fractures after a fall from bed, and required emergency medical care.

Inspectors wroteBased on interview and document review, the facility failed to ensure a resident's primary medical provider was notified of changes in condition for 1 of 1 resident (R1) who exhibited increased pain and extremity swelling after a fall, which required x-ray services, along with failure to ensure a physician order was acted upon for R1 after she returned from the emergency department (ED).

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure enhanced barrier precautions (EBP) were implemented with the use of personal protective equipment (PPE) during high-contact resident care activities for 1 of 1 residents (R39) who had a central line, 1 of 1 residents (R38) who had wound dressings changed, and 1 of 3 residents (R11) observed during personal cares. The facility also failed to ensure appropriate hand hygiene was utilized for 1 of 2 residents (R38) observed during personal cares, and failed to ensure shared resident equipment was disinfected between uses for 1 of 1 residents (R3) observed for shared equipment. Lastly, the facility failed to ensure re-usable ice packs for clinical use were stored separately from food storage in 3 of 3 kitchen refrigerators.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a multi-resident shower room ceiling exhaust fan was cleaned. This had the potential to affect all residents on the third floor who used the shower room.

Inspectors wroteBased on interview and document review, the facility failed to ensure a resident's right to determine their own healthcare decisions for 1 of 1 resident (R30), and failed to ensure R30 had a right to revoke a power of attorney.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician of a change in condition for 1 of 1 resident (R18) who was experiencing new vision loss.

Inspectors wroteBased on interview, and document review, the facility failed to ensure residents were invited to care conferences for 1 of 1 resident (R30) reviewed for care planning.

Inspectors wroteBased on observation and interview, the facility failed to ensure swallow study referral discharge needs were identified in the post-discharge plan for 1 of 1 resident (R54) reviewed for discharge.

Inspectors wroteDuring observation, interview, and record review the facility failed to ensure that residents received proper treatment to maintain vision for 1 of 1 resident (R18) reviewed for vision services.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure resident was adequately assessed for safe smoking for 1 of 1 resident (R15) reviewed for smoking. In addition, the facility failed to ensure an identified safety hazard was acted upon for 1 of 2 residents (R50) reviewed for resident to resident abuse.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure supplemental oxygen was properly maintained and accurately documented per professional standards for 1 of 1 resident (R20).

Inspectors wroteBased on interview and document review the facility failed to ensure 2 of 5 residents (R5 and R20) were offered and/or provided updated vaccinations for pneumococcal disease in accordance with the Centers for Disease Control (CDC) vaccination recommendations.

Inspectors wroteBased on interview and document review, the facility failed to report an allegation of resident sexual abuse to the State Agency (SA) immediately, but not later than two hours after the allegation is made, for 1 of 1 resident (R1) reviewed who reported an allegation of sexual abuse in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to monitor edema and comprehensively assess non-pressure related wounds for 1 of 1 resident (R2) reviewed. Findings Include: R2's admission Minimum Data Set (MDS) dated [DATE], indicated R2 was admitted on [DATE] with diagnoses including malignant neoplasm of brain (brain cancer), hypertension, and chronic ischemic heart disease (weakening of the heart caused by reduced blood flow) and was receiving hospice care. R2's active physician order dated 2/19/24, directed nurses to chart R2's condition in nurse's notes every shift for edema (fluid retention in body tissues that can result in swelling and/or weight gain) checks noting edema as present or not present and lung checks noting lungs as clear or not clear. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nursing cares in a sufficient amount of time for ten of ten residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10) reviewed for call light times. R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10 depend on staff for assistance in their activities of daily living and there are delays in cares during to these call light times.

Inspectors wroteBased on interview and record review, the facility failed to protect the dignity of three of ten residents (R3, R6, R8) reviewed when residents were left soiled in their incontinent brief for extended periods of time.

Inspectors wroteBased on interview and document review, the facility failed to ensure a baseline care plan was reviewed and provided timely to ensure knowledge of care and promote person-centered care planning for 1 of 2 residents (R24) reviewed for care planning.

Inspectors wroteBased on interview and document review, the facility failed to revise the care plan for 1 of 1 resident (R54) reviewed for ongoing medication refusals.

Inspectors wroteBased on observation, interview, and document review, the facility failed to monitor skin conditions for 1 of 1 resident (R238) who had facial bruising upon admission. The facility also failed to ensure physician's orders were accurately transcribed for 1 of 1 resident (R13)reviewed who required follow-up care after skin excisions.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure interventions were in place for 1 of 2 residents (R12) at risk for pressure ulcers.

Inspectors wroteBased on interview, and document review, the facility failed to ensure the medical record reflected accurate care and monitoring of the dialysis access site for 1 of 1 residents (R23) reviewed for dialysis.

Inspectors wroteBased on interview and document review, the facility failed to assess for and identify potential triggers for 1 of 1 resident (R28) who had a history of trauma.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure antibiotic medications had appropriate monitoring, diagnosis, and indication for use for 1 of 1 resident (R15) reviewed for unnecessary medications.

Inspectors wroteBased on interview and document review, the facility failed to implement protocols to ensure appropriate antibiotic treatment was in place for 1 of 1 resident (R15) with an active infection. Furthermore, the facility failed to ensure monitoring and documentation of prophylactic antibiotic use for 1 of 1 resident (R15) reviewed for antibiotic stewardship. R15's quarterly minimum data set (MDS) dated [DATE], indicated a brief interview for mental status (BIMS) score of 15, and R15 has an indwelling urinary catheter. R15's provider orders (after visit summary) dated 8/11/23, included the medications Bacitracin and cefpodoxime (oral antibiotic), and follow-up visit dated 9/5/23, included Bactrim and Bacitracin. [...]