Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mapleton Post Acute during CMS and state inspections, most recent first.
A resident with significant cognitive and physical impairments was discharged from Medicare Part A skilled therapy services, but the required written Medicare Notice of Non-Coverage (NOMNC) was not provided to the resident's representative. Although verbal notification was given, there was no documentation of a mailed notice or written confirmation in the EMR, and the representative remained unaware of the change in coverage. Staff interviews confirmed the omission and incomplete documentation.
A resident with cognitive impairment and multiple medical conditions was discharged to another SNF without proper documentation of the discharge planning process in the EMR. The facility did not provide written notification to the resident, the representative, or the ombudsman, omitting required details such as the reason for discharge, effective date, discharge location, appeal rights, and ombudsman contact information. Staff interviews confirmed these omissions.
The facility failed to ensure proper storage and labeling of medications, with incidents involving unsecured medications at residents' bedsides and unattended medication carts. A resident was found with unsecured self-administered medications, and another had a medication left at the bedside without authorization. Additionally, the medication storage room was insecure, and medications were left unattended on carts, posing potential risks.
A facility failed to monitor vital signs before administering blood pressure medications to three residents, contrary to professional standards. One resident with hypertension and other conditions received Metoprolol without vital sign checks, while another with heart issues was given Amiodarone without reviewing blood pressure or pulse parameters. A third resident with hypertension and chronic kidney disease was administered Amlodipine without vital sign monitoring. Interviews revealed a practice of weekly vital sign checks for LTC residents, which did not meet professional standards.
The facility failed to maintain proper infection control practices, as an LPN did not sanitize glucometers before or after use, and a housekeeper did not adhere to disinfection guidelines for resident rooms. Observations showed that the LPN neglected to clean glucometers between uses, while the housekeeper did not allow disinfectants to remain on surfaces for the required time and failed to clean high-touch areas. Staff interviews confirmed these lapses in protocol adherence.
A facility failed to provide a restorative nursing program for a resident with limited range of motion, necessary to maintain or improve her mobility. The resident, diagnosed with Alzheimer's, CKD, and osteoarthritis, was not involved in a restorative program during the assessment period. The program was discontinued in July 2024 due to financial and staffing issues, with no immediate plans for reinstatement. The resident's care plan lacked documentation of involvement in a restorative program, and previous services were halted after June 2024.
The facility failed to provide effective discharge planning for two residents, leading to deficiencies in their transition to VA facilities. One resident, with severe cognitive impairment, was not assisted in finding a VA facility, and the care plan was not updated. Another resident, who was cognitively intact, was not supported in moving to a VA facility in another state, resulting in a missed flight and readmission. The facility lacked coordination and communication with VA resources, contributing to the deficiencies.
Failure to Provide Written Medicare Non-Coverage Notice to Resident's Representative
Penalty
Summary
The facility failed to provide timely and appropriate written notification to a resident's representative regarding the termination of Medicare Part A skilled therapy services. According to facility policy, when a resident is no longer eligible for Medicare-covered services, the provider must notify the resident or their representative both verbally and in writing, including by mail if verbal contact is made. In this case, the social services director (SSD) verbally notified the resident's representative by phone that skilled therapy services would be ending, but did not follow up with a written Medicare Notice of Non-Coverage (NOMNC) as required. Record review showed that the NOMNC form lacked documentation of a mailed notice, and there was no evidence in the electronic medical record (EMR) that a written notice was sent to the representative. The resident's representative reported not receiving any written notification about the change in Medicare coverage and was unaware that skilled therapy services had ended, believing the resident was still receiving those services. The resident, who had diagnoses including cerebral palsy, monoplegia, and peripheral vascular disease, also had documented memory deficits, making proper notification to the representative especially important. Interviews with facility staff, including the SSD, director of rehabilitation (DOR), and nursing home administrator (NHA), confirmed that the required written NOMNC was not provided to the resident's representative. Staff acknowledged their responsibility for notification and described the process, but admitted that in this instance, the written notice was not sent and documentation was incomplete. The NHA was unaware that a written copy of the NOMNC was required to be provided to the representative and that documentation of delivery was missing from the EMR.
Failure to Document and Notify Required Parties During Resident Discharge
Penalty
Summary
The facility failed to properly document and implement an effective discharge plan for one resident who was reviewed for discharge planning. Specifically, the facility did not ensure that the discharge planning process was documented in the resident's electronic medical record (EMR), including the reason for discharge. The resident, who was cognitively impaired with a BIMS score of five out of 15 and had diagnoses including anoxic brain injury, alcohol dependence, chronic pancreatitis, and accidental opioid poisoning, was discharged to another skilled nursing facility. The care plan and assessments did not reflect active discharge planning or the resident's need for a facility that accommodated smoking, which was a factor in the discharge. The facility also failed to provide written notification to the resident and the resident's representative regarding the discharge. The letter sent to the representative did not include required information such as the reason for discharge, the effective date, the location of discharge, a statement of appeal rights, or the contact information for the state long term care ombudsman. There was no evidence in the EMR that the resident or representative received proper written notification after the initial letter, nor was there documentation that the ombudsman was notified in writing about the discharge. Interviews with facility staff confirmed these deficiencies. The social services director acknowledged that the required information was not included in the letter to the representative and that no letter was sent to the ombudsman. The nursing home administrator also confirmed that the necessary written notifications were not provided to the resident, the representative, or the ombudsman. Additionally, a frequent visitor with knowledge of the facility and the resident was unaware of the discharge and had not received any written or electronic notification.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were properly stored and labeled, as observed in two units. Resident #33 was allowed to self-administer medications, but the medications were found unsecured on the bedside table. The Director of Nursing (DON) confirmed that the resident had a physician's order to self-administer but acknowledged that the medications should not have been left unsecured, as other residents could access them. Additionally, the medication storage room was found to be insecure, as the DON was able to open the door without entering the code, indicating a failure to maintain secure access to medications. Another incident involved Resident #28, where a yellow tablet was left unattended on the bedside table. The resident stated that the nurses left the medication there, and RN #2, who was interviewed, did not know what type of medication it was and did not remove it. A review of the resident's medical record showed no indication that the resident was assessed to self-administer medications. The DON confirmed that Resident #28 was not capable of self-administering medications due to her condition. Furthermore, medications were left unattended on medication carts. On one occasion, a triple antibiotic cream was observed on top of a medication cart without a nurse nearby. Later, a tube of Aspercream, a bottle of magnesium oxide tablets, and another tube of triple antibiotic cream were also left unattended on a cart. LPN #1 and the DON acknowledged that medications should not be left unattended, as residents could access them and potentially harm themselves. The DON emphasized the importance of securing medications to prevent unauthorized access by residents.
Failure to Monitor Vital Signs Before Administering Blood Pressure Medications
Penalty
Summary
The facility failed to adhere to professional standards of practice by not monitoring vital signs prior to administering blood pressure medications to three residents. Resident #39, who was diagnosed with hypertension, diabetes mellitus, and an abdominal aortic aneurysm, was given Metoprolol without checking the order for blood pressure parameters or reviewing recent vital signs. The facility's computerized physician orders did not specify vital sign parameters for withholding the medication, and vital signs were only checked weekly instead of daily. Resident #22, with diagnoses including congestive heart failure and atrial fibrillation, received Amiodarone without a review of blood pressure or pulse parameters. The computerized physician orders lacked instructions for when to hold the medication based on vital signs, and the resident's vital signs were not assessed daily as required. Similarly, Resident #52, diagnosed with hypertension, diabetes mellitus, and chronic kidney disease, was administered Amlodipine without checking vital signs or parameters, with vital signs only recorded weekly. Interviews with RN #1 and the assistant director of nursing revealed a facility practice of checking vital signs weekly for long-term care residents unless specific parameters were ordered. The facility's philosophy aimed to create a homelike environment, which led to less frequent monitoring of vital signs. However, this practice did not align with the professional standards requiring vital sign assessments before administering blood pressure medications.
Infection Control Deficiencies in Glucometer Sanitization and Room Cleaning
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by improper sanitization of glucometers and inadequate cleaning of resident rooms. Observations revealed that a Licensed Practical Nurse (LPN) did not clean or disinfect glucometers before or after use for multiple residents. This practice is contrary to the facility's policy, which requires glucometers to be cleaned and disinfected before and after each use with an EPA-registered healthcare disinfectant. The LPN acknowledged the oversight, despite being aware of the correct procedure. Additionally, the facility did not ensure that resident rooms were cleaned in a sanitary manner. A housekeeper was observed failing to allow disinfectant to remain on surfaces for the required contact time to achieve effective disinfection. The housekeeper also did not change gloves or perform hand hygiene after cleaning potentially contaminated areas, such as toilets, before handling clean supplies or touching the housekeeping cart. High-touch surfaces, such as light switches and door knobs, were not cleaned as required. Interviews with staff confirmed the deficiencies in both glucometer sanitization and room cleaning practices. The assistant director of nursing and the housekeeping supervisor reiterated the importance of following proper procedures to prevent the spread of infections. However, the observed practices did not align with the facility's policies or the manufacturer's guidelines, indicating a lapse in adherence to infection control protocols.
Facility Fails to Provide Restorative Nursing Program for Resident
Penalty
Summary
The facility failed to provide a restorative nursing program for a resident with limited range of motion, which was necessary to maintain or improve her mobility and prevent further decline. The resident, who was over 65 years old and diagnosed with Alzheimer's disease, chronic kidney disease, and osteoarthritis, was not involved in a restorative nursing program during the assessment period. Despite the resident's representative expressing concerns about the resident's mobility and the need for a restorative program, the facility did not have such a program in place. Observations and interviews revealed that the facility had discontinued its restorative nursing program in July 2024 due to financial constraints and staffing issues. The Director of Rehabilitation acknowledged the absence of the program and indicated that the facility was in the process of reorganizing and reinstating it. However, there was no specific timeline for when the program would be available again. The resident had previously received restorative services, including active range of motion exercises, until the program was discontinued. The facility's failure to provide a restorative nursing program was further highlighted by the lack of documentation in the resident's care plan regarding her involvement in such a program. The care plan did not include any personalized restorative nursing program plan, and there was no documentation of restorative services being offered after June 2024. Interviews with the Director of Nursing and the Physical Therapy Assistant confirmed the discontinuation of the program and the facility's intention to restore it, but no immediate solutions were provided to address the resident's needs.
Inadequate Discharge Planning for Residents
Penalty
Summary
The facility failed to develop and implement an effective discharge plan for two residents, leading to deficiencies in their discharge process. Resident #128, who had severe cognitive impairment and multiple medical conditions, was not provided with adequate assistance in transitioning to a VA facility. Despite the representative's request for help in finding a VA facility that would accept the resident's benefits, the social services director did not offer assistance or make necessary referrals. The resident's care plan was not updated to reflect the family's request, and there was no documentation of interdisciplinary team meetings or care conferences regarding the discharge planning. Resident #125, who was cognitively intact and independent in functional abilities, also experienced inadequate discharge planning. The resident expressed a desire to move to a VA facility in a different state, but the facility did not assist in making the necessary arrangements. The social services assistant was unaware of the resident's preference, and there was no documentation of contact with the VA facility to ensure a safe discharge. The resident ended up missing a flight and staying at the airport for several days before being readmitted to the facility. Interviews with the social services director and nursing home administrator revealed a lack of knowledge and experience in handling VA resources and referrals. The facility's discharge planning process did not involve the necessary coordination and communication with VA facilities, resulting in inadequate support for the residents' discharge goals. The facility's failure to document and follow through with the residents' discharge plans contributed to the deficiencies identified in the report.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lakewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oakwood Care And Rehabilitation | 0.5 mi | ★★★★★ | 30 | 0 |
| Sierra Post Acute | 1.4 mi | ★★★★★ | 10 | 0 |
| Cedars Healthcare Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Edgewater Health And Rehabilitation | 1.7 mi | ★★★★★ | 14 | 0 |
| Cambridge Care Center | 1.7 mi | ★★★★★ | 0 | 0 |
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