Maplewood Center

In the surveyor’s words

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

• Immediate jeopardy, patternF689May 1, 2025

  Based on observation, interview, and record review, the facility did not ensure Residents received adequate supervision and assistive devices to prevent accidents for 11 (R49, R72, R83, R12, R315, R79, R100, R51, R38, R94, and R6) of 14 Residents reviewed for accidents. This has the potential to affect 64 residents who use a mechanical hoyer lift, a mechanical sit to stand, or a Sara Steady lift. Staff did not always use the correct lift or use it correctly. The facility does not have a process in place for staff to ensure residents that are transferred using a mechanical lift or sit to stand have the appropriate sling to use during the transfer. *On 3/23/25, R72 fell from a Sara Steady and suffered a displaced spiral fracture of the left femur. […]

• Immediate jeopardy, patternF695Feb 13, 2025

  Based on observation, interview, and record review the facility did not ensure the necessary Respiratory Therapy services to provide respiratory care consistent with professional standards of practice to 2 (R7 and R1) of 3 residents reviewed for respiratory cares/ services. The facility did not ensure staff were trained, knowledgeable and competent to provide respiratory care to 9 residents who are ventilator dependent and 7 residents who are not ventilator dependent but have tracheostomies (trach). *On 01/25/2025, R7 was not put on R7's ventilator at night due to the Facility not having a Respiratory Therapist at the Facility. R7 did not have Respiratory orders relating to R7's ventilator. […]

• Immediate jeopardy, isolatedF684Feb 13, 2025

  Based on interview and record review, the Facility did not ensure a resident received treatment and care in accordance with professional standards of practice to include individual assessment and reporting when experiencing a medical change of condition, per standards of practice for respiratory therapists. This was discovered with 1 (R2) of 1 resident reviewed that had a medical change of condition while on a ventilator. On [DATE], at 11:12 PM, there was a progress note written by the Respiratory Therapist (RT)-T that indicated shortness of breath was present for R2 and that this was new, not chronic. RT-T raised R2's oxygen flow rate from 5 lpm (liters per minute) to 8 lpm. […]

• Immediate jeopardy, isolatedF689Jan 13, 2024

  Based on interviews and record reviews, the facility failed to implement interventions when 1 of 6 residents (R5) reviewed for elopement out of a total sample of 11 was assessed as being at risk for elopement. R5, who was described as extremely confused, was assessed as being high risk for elopement on 12/14/23 and should have had a departure alert bracelet in place at that time. R5 was last seen on 12/16/23 between 4:00 PM and 4:15 PM. Staff identified that R5 was not in the building at 4:30 PM. R5 crossed a heavily traveled 4 lane street and was found by a neighbor in their yard at 4:50 PM. The resident was outside unsupervised and without the staff's knowledge of the resident's whereabouts for approximately 20 minutes. […]

• Immediate jeopardy, isolatedF689Dec 28, 2022

  Based on observation, interview and record review, the facility did not ensure that 1 (R32) of 12 residents at high risk for elopement were not provided with safety measures, interventions and assessments to prevent elopement; 1 (R329) of 5 residents with falls followed Care Plan to prevent falls; 12 (R80 and R11) of 24 residents reviewed for environment were provided with a safe environment; and 1 (R40) of 1 resident who smoked was assessed to be a safe smoker. 1. R32 was assessed as a high elopement risk and demonstrated active wandering behavior and desire to leave facility starting on 10/2/22. Facility placed a Wanderguard on and initiated a Care Plan. Facility stated they initiated 1:1 monitoring but that was not put in place until 11/6/22. R32 continued to have wandering behaviors. […]