Maplewood Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF678Oct 12, 2021

  Based on interview and document review, the facility failed to initiate cardiopulmonary resuscitation (CPR) in accordance with Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in an immediate jeopardy (IJ) when R3 was found absent of pulse and respirations, CPR was not initiated and R3 died . The facility implemented corrective action, so the deficient practice is being issued at past non-compliance. The IJ began on [DATE], when R1 was found unresponsive without a pulse or respirations, CPR was not initiated. The administrator and director of nursing (DON) were notified of the IJ on [DATE], at 4:29 p.m. […]

• Immediate jeopardy, isolatedF678Aug 3, 2021

  Based on interview and document review, the facility failed to immediately initiate cardiopulmonary resuscitation (CPR) in accordance with Provider Orders for Life-Sustaining Treatment (POLST) for 1 of 3 residents, found without a pulse or respirations. CPR was not immediately initiated and R1 died . This deficient practice had the potential to affect 34 of 81 residents who resided at the facility and who had orders for CPR to be performed. The Immediate Jeopardy (IJ) began on [DATE], at 10:55 a.m. when R1 was found without a pulse or respirations, and CPR was not immediately initiated. The administrator and director of nursing (DON) were informed of the IJ on [DATE], at 4:43 p.m. […]

• Actual harm, isolatedF689Jul 9, 2025

  Based on interview and document review, the facility failed to implement individualized interventions to reduce the risk of falls for 1 of 3 residents (R1) reviewed for accidents. This resulted in actual harm for R1 who sustained fractures after a fall from bed, and required emergency medical care. Findings include: R1's significant change Minimum Data Set (MDS) Falls CAA (Care Area Assessment) Worksheet, dated 11/6/24, identified R1 was diagnosed with vascular dementia, end stage chronic disease, diabetes, bipolar disorder, and pain syndrome. She required staff assistance and triggered falls related to daily scheduled antianxiety medications. She was free of falls in the past year. She was enrolled in hospice (end of life) care since 6/2022. R1 was non-ambulatory and was bed-bound. […]

• No harm, potential for more than minimal, widespreadF867Dec 4, 2025

  Based on interview and document review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program effectively sustained ongoing compliance related to repeat citations for past surveys regarding provider notification of changes, care plan revisions, arrangement of hearing appointments, oxygen administration, and infection control practices. This had the potential to affect all 101 residents residing in the facility. Findings include:Review of the facility Certification and Survey Provider Enhanced Reports (CASPER)-3 (assessment data was converted to quality measures [QM] to evaluate nursing home's performance) dated11/25/25, identified the following prior deficiencies by month and year. […]

• No harm, potential for more than minimal, widespreadF725Jan 30, 2024

  Based on observation, interview, and record review, the facility failed to provide nursing cares in a sufficient amount of time for ten of ten residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10) reviewed for call light times. R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10 depend on staff for assistance in their activities of daily living and there are delays in cares during to these call light times. Findings include: R1's admission record printed on 2/1/24 indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of schizoaffective disorder bipolar type and obesity. Additional pertinent diagnoses include morbid obesity, urge incontinence, limitation of activities due to disability, dependence on wheelchair, and muscle weakness. […]