Mapleton Post Acute

In the surveyor’s words

From the most serious findings on record at Mapleton Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF697Mar 19, 2024

  Based on record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans and resident preferences for one (#2) of three residents reviewed for pain management out of five sample residents. The facility failed to ensure Resident #2, with a diagnosis of chronic low back pain, low back compression fractures, spinal stenosis (spaces inside bones get small putting pressure on spinal cord), spinal fusion, history of infection in the back with sepsis (infection of the bloodstream), repeat falls and anxiety, was administered scheduled pain medication as ordered. […]

• No harm, potential for more than minimal, widespreadF761Dec 5, 2024

  Based on observation and interviews, the facility failed to ensure all drugs and biological used in the facility were properly stored and labeled in two out of two units. Specifically, the facility failed to: -Ensure medications that were self administered were stored securely at the bedside for Resident #33; -Ensure a medication storage room was securely locked; -Ensure medications that were not administered were not left unsecured at Resident #28's bedside; and, -Ensure medications were not left unattended on medication and treatment carts. Findings include: I. Facility policy and procedure The Medication Access and Storage policy and procedure, reviewed November 2022, was provided by the nursing home administrator (NHA) on 12/5/24 at 11:08 a.m. […]

• No harm, potential for more than minimal, widespreadF760Mar 19, 2024

  Based on record review and interviews, the facility failed to ensure residents were kept free from significant medication errors for five (#2, #3, #4, #5 and #1) of five residents reviewed for medication errors. Specifically, the facility failed to ensure Residents #2, #3, #4, #5 and #1 received medications according to the physician's orders which resulted in significant medications errors. The failure to ensure medications were given according to physician orders affected all five sample residents and was recognized to affect all other residents prescribed medications in the facility. Record review and interviews showed the facility systematically had problems with the pharmacy filling orders and staff ordering medications. Findings include: I. […]

• No harm, potential for more than minimal, widespreadF867Mar 19, 2024

  Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns were implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to quality of care. Findings include: I. Facility policy and procedure The facility QAPI policy was requested from the nursing home administrator (NHA) on 3/19/24 at 10:58 a.m. -The policy was not received by the end of the survey on 3/19/24. II. […]

• No harm, potential for more than minimal, widespreadF851Jun 29, 2023

  Based on record review and interviews, the facility failed to ensure mandatory submission of direct care staffing based on payroll roll data. Specifically, the facility failed to ensure staffing data entered in the Payroll-Based Journal (PBJ) system was accurate. Findings include: The facility had a change of ownership on 3/1/23. I. Record review The PBJ stuffing report for quarter two (1/31/23 to 3/31/23) showed the following triggered areas: -Excessively low weekend staffing; -No registered nurse (RN) hours; and -Failed to have licensed nursing coverage 24 hours a day. January and February 2023 staffing data was not entered in the PBJ system; the following information was generated from March 2023. II. Interview Nurse consultant #2 was interviewed on 6/29/23 at 5:00 p.m. […]