Maplewood Health Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Mar 3, 2025

  Based on policy review, facility daily staffing review, medical record review, hospital record review, and interview, the facility failed to ensure residents were free of neglect as evidenced by the facility's failure to provide sufficient licensed nursing staff to perform assessments and administer morning medications as ordered for 6 of 6 (Resident #1,#2, #3, #4, #5, and #6) sampled residents reviewed. The facility's failure resulted in Immediate Jeopardy (IJ) when Resident #1 experienced a change of condition, and a nurse was not available on the 100 Hall to assess Resident #1. Resident #1's spouse called 911. Resident #1 was evaluated in the Emergency Department (ED) and admitted to the hospital. […]

• Actual harm, isolatedF686Jan 15, 2025

  Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services to prevent the development of a pressure ulcer/injury and failed to provide treatments for 2 of 4 (Residents #72, and #85) sampled residents reviewed for pressure ulcers/injuries. Resident #72, who was at risk of developing pressure ulcers/injuries due to contractures [a permanent tightening of muscles, tendons, ligaments, skin, or other tissues that limits movement of a joint or body part] of the extremities and was dependent on staff for preventative interventions, developed a pressure ulcer/injury to the palm of her left hand from having long fingernails embedded into the skin, resulting in actual Harm to Resident #72. The findings include: 1. […]

• Actual harm, isolatedF689Jan 15, 2025

  Based on policy review, medical record review, facility investigation review, and interview, the facility failed to implement fall interventions for 1 of 4 (Resident #56) sampled residents reviewed for falls. The facility failed to follow the fall prevention intervention of 2 person bed mobility assistance, when on 11/17/2024, Resident #56 fell out of the bed and sustained a fractured hip, resulting in Actual HARM to Resident #56. The findings include: 1. Review of the facility's undated policy titled, Fall Prevention Program, revealed .Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls .The nurse will indicate the resident's fall risk . […]

• Actual harm, isolatedF580Aug 19, 2022

  Based on review of the National Pressure Ulcer Advisory Panel (NPUAP) Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] #42) reviewed with in-house acquired pressure ulcers. The facility's failure to notify the Wound Care Nurse of skin condition changes/redness and to notify the Physician and obtain orders for a newly identified pressure ulcer resulted in actual Harm when skin condition changes deteriorated and progressed to an Unstageable pressure ulcer. The findings include: Review of the National Pressure Ulcer Advisory Panel (NPUAP) Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. […]

• Actual harm, isolatedF686Aug 19, 2022

  Based on review of the National Pressure Ulcer Advisory Panel (NPUAP) Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] #42 and #99) reviewed with in-house acquired pressure ulcers. The facility's failure to identify, assess, report, and provide treatment before newly identified skin changes and pressure ulcers deteriorated and progressed to Unstageable pressure ulcers resulted in actual Harm for Resident #42 and Resident #99. The findings include: Review of the National Pressure Ulcer Advisory Panel (NPUAP) Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .Conduct a comprehensive skin and tissue assessment for all individuals at risk of pressure injuries: As soon as possible after admission/transfer to the healthcare service .As a part of every risk… […]