Maplewood Center

In the surveyor’s words

From the most serious findings on record at Maplewood Center, in the surveyor’s own words.

• Actual harm, patternF686Jun 5, 2025

  4. For Resident #69 the facility failed to a. ensure that treatment provided to a stage 4 left heel pressure ulcer was implemented in accordance with the wound consultant, and b. failed to ensure treatment to a deep tissue injury to Resident #69's left heel was provided in accordance with the physician's orders. Resident #69 was admitted to the facility in November 2024 with diagnoses that include but not limited to paralytic gait, acute respiratory failure with hypoxia, unspecified severe protein-calorie malnutrition, and Alzheimer's disease. […]

• Actual harm, isolatedF600Jun 13, 2024

  Based on observations, interviews and record review, the facility failed to provide a safe environment free from abuse for one Resident (#41) out of a sample of 24 residents. Specifically, the facility failed to provide an environment free from physical, sexual and mental abuse. Findings include: Review of the facility policy titled 'Clinical Services, Subject: Abuse' with a revision date of March 2023 indicated the following: It is the policy of the facility that each resident has the right to be free from abuse, neglect and misappropriation of resident property and exploitation. It is the philosophy of the facility to encourage an environment that recognizes the special qualities of our residents and provides them with a safe environment. […]

• Actual harm, isolatedF607Jun 13, 2024

  Based on observations, interviews and record review, the facility failed to implement their abuse policy for one Resident (#41) out of a sample of 24 residents. Specifically, 1. The Director of Nurses (DON) and Assistant Director of Nurses (ADON) failed to notify the Administrator about allegations of physical, sexual and mental abuse, 2. Keep Resident #41 safe by suspending the staff member involved in the abuse allegations, 3. Failed to report and investigate the abuse allegations as required, and 4. […]

• Actual harm, isolatedF609Jun 13, 2024

  Based on observations, interviews and record review, the facility failed to report an allegation of abuse for one Resident (#41) out of a sample of 24 residents. Specifically, the facility failed to report allegations of physical abuse, sexual abuse and mental abuse to the (SA) state agency. Findings include: A review of the facility policy titled 'Clinical Services, Subject: Abuse' with a revision date of March 2023 indicated the following: It is the policy of the facility that each resident has the right to be free from abuse, neglect and misappropriation of resident property and exploitation. It is the philosophy of the facility to encourage an environment that recognizes the special qualities of our residents and provides them with a safe environment. […]

• Actual harm, isolatedF610Jun 13, 2024

  Based on observations, interviews and record review, the facility failed to investigate allegations of abuse for one Resident (#41) out of a sample of 24 residents. Specifically, the facility failed to investigate allegations of physical, sexual and mental abuse. Findings include: Review of the facility policy titled 'Clinical Services, Subject: Abuse' with a revision date of March 2023 indicated the following: It is the policy of the facility that each resident has the right to be free from abuse, neglect and misappropriation of resident property and exploitation. It is the philosophy of the facility to encourage an environment that recognizes the special qualities of our residents and provides them with a safe environment. […]