Maplewood Nursing and Rehab Center

In the surveyor’s words

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

• Immediate jeopardy, patternF689Jan 12, 2024

  Based on observation, review of facility policies, facility documentation and interviews with staff, it was determined that the facility failed to ensure that water temperatures in resident bathroom hand sinks and shower rooms were maintained at a safe temperature for three of three nursing units (Second, Third and Fourth Floor Nursing Units). This failure placed residents on the (Second, Third and Fourth Floor Nursing Units) at risk for serious injury from a burn and resulted in an Immediate Jeopardy situation. (Second, Third and Fourth Floor Nursing Units). […]

• Immediate jeopardy, isolatedF695Aug 7, 2026

  Based on review of facility policy, facility documentation, clinical records, observations, and staff interviews it was determined the facility failed to ensure emergency equipment readily available for accidental extubation for a resident with a tracheostomy (An extubation creates an emergency situation that requires that an obturator be readily available that can be used by competent staff for reinsertion) for one of two residents reviewed (Resident R130). Facility staff were unaware of the location of emergency equipment or how to use it in case of accidental extubation, resulting in an Immediate Jeopardy situation (Resident R130). […]

• Actual harm, isolatedF689Aug 15, 2024

  Based on review of facility policy, review of facility documentation, review of clinical records, and interviews with residents and staff, it was determined that the facility failed to ensure that the resident environment remained free of accident hazards by failing to monitor the temperature of hot water beverages served to a resident. This failure resulted in actual harm to Resident R1 who spilled a hot water beverage and sustained an abdominal and chest burn injury, for one of five residents reviewed. (Resident R1) Findings include: Review of facility policy on Hot Liquid with a most recent revision date of January 17, 2019, revealed that under section Policy: Residents will be served coffee, hot water, soup, or any hot liquid at a palatable temperature that will not burn the skin. […]

• Actual harm, isolatedF656Feb 16, 2023

  Based on observations, a review of the clinical record, interviews with staff, and review of facility policy, it was determined that the facility failed to develop a person- centered care plan related to contractures of Resident R67's hands. This failure resulted in actual harm to Resident R67 who developed one abscess on the crease of the left wrist requiring antibiotic therapy and the development of a second abscess on the palm of the right hand requiring a surgical debridement and intravenous antibiotic therapy for one of 34 residents reviewed. […]

• Actual harm, isolatedF684Feb 16, 2023

  Based on observations, staff interview and facility documentation, and review of facility policy, it was determined that facility failed to ensure that treatment was provided to Resident R67's bilateral hand contractures with the use of hand gauzes to prevent the development of bilateral hand wounds. This failure resulted in actual harm to Resident R67 who developed one abscess on the crease of the left wrist requiring antibiotic therapy and the development of a second abscess on the palm of the right hand requiring a surgical debridement and intravenous antibiotic therapy for one of 34 residents reviewed (Resident 67). The facility failed to follow physician's orders related to the administration of insulin medication for one of 34 residents reviewed. […]