Maplewood Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF755Nov 7, 2023

  Based on record review and staff interview, the facility failed to ensure medications were available for administration to residents. This deficient practice had the potential to affect two (2) of three (3) residents reviewed for medications. This deficient practice caused harm to Resident #15. Resident #15 experienced seizures as a result of not receiving anticonvulsant medication as ordered and required an emergency room evaluation and medical testing. Resident identifiers: #15 and #24. Facility census: 76. Findings included: a) Resident #15 Resident #15 was admitted in August 2023. He had diagnoses of cerebral palsy, seizures, and moderate intellectual disabilities. […]

• No harm, potential for more than minimal, widespreadF803Jun 11, 2026

  Based on observation, staff interview, resident interview, and record review, the facility failed to ensure residents received the portions specified on the facility's approved production sheets and failed to consistently provide menu items as planned. This deficient practice had the potential to affect all residents receiving meals from the facility's dietary department. Facility census: 76Findings include: During an observation of the lunch tray line on 06/10/26 beginning at approximately 12:30 p.m., [NAME] #94 was observed serving roasted squash. The facility's serving utensil was a four (4) ounce scoop; however, the scoop was not filled to capacity. The scoop was frequently less than half full and at times only approximately half full before being placed on resident trays. […]

• No harm, potential for more than minimal, widespreadF641Mar 6, 2024

  Based on staff interview and record review, the facility failed to ensure a qualified staff person assessed each resident's activity pursuits by not providing a qualified activity professional. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents residing in the facility. Facility census: 76. Findings included: a) During an interview, on 03/05/24 at 01:00 PM, with Activity Director (AD), she stated she was currently enrolled in the Modular Education Program for Activity Professionals (MEPAP) class and had been employed since May of 2023. […]

• No harm, potential for more than minimal, widespreadF803Mar 6, 2024

  Based on observation and staff interview, the facility failed to ensure the correct alternative menus were posted to be available if the primary menu or immediate selections for a particular meal are not to a resident's liking. This was a random opportunity for discovery, and currently no residents are receiving enteral tube feedings in the facility, therefore; this failed practice had the potential to affect all residents residing in the facility. Facility Census: 76 Findings include: On 03/05/24 at 10:00 AM an Always available menu was observed posted by the daily menus near the dining room showing the following substitutes. […]

• No harm, potential for more than minimal, patternF865Jan 14, 2026

  Based on facility documentation and staff interviews, the facility failed to have/keep the required documentation for Quality Assessment meetings (QAA). Additionally, the facility did not have required attendees present or sign in at the Quality Assessment and Assurance (QAA) meeting logs. This failed practice had the potential to affect all residents residing at the facility. Facility Census: 76. Findings included: During an interview with both the Director Of Nursing and Regional Director Clinical Operations (RDCO) on 01/14/26 at approximately 8:50 AM, both stated they had been looking for the Quality Assurance (QAPI/QAA) books or records since the survey team entered the facility. Unfortunately, they were unable to locate documentation to show their meetings and what was discussed. […]