Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Community Home during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, total dependence for ADLs, incontinence, and a stage 4 sacral PU was not checked, changed, or repositioned for more than four hours while attending meals and activities. Staff observed a wet diaper and redness to the buttocks after prolonged sitting, and the DON confirmed camera footage showed the resident was not offloaded as ordered every two hours.
Unsafe Resident Bathroom Water Temperatures: Two residents who used their bathrooms independently were observed with faucet water that felt excessively hot. One resident had Parkinson’s disease and the other had CKD; both had intact cognition and used walkers/wheelchairs. The DES measured bathroom water temperatures above 120°F at both rooms and stated he did not regularly check or document water temperatures, though he knew resident bathroom water should not exceed 120°F due to scalding risk.
Failure to use required PPE during wound care occurred when staff cared for a resident with multiple chronic pressure ulcers and open wounds without gowns or EBP signage. An RN and NA wore gloves while rolling the resident, changing a brief, and completing wound care, but did not wear gowns. The DON, who also served as the IP, stated the resident should have been on EBP and acknowledged misinterpreting the facility’s EBP guidance.
The facility failed to ensure dietary staff followed infection control practices, as dietary aides were observed handling cups by the rim with bare hands during food service. Despite having received training, the aides acknowledged their improper handling, which contradicted the facility's policy on dish and utensil handling.
The facility failed to follow infection control practices in wound care, equipment cleaning, and laundry handling. A resident's overbed table was not cleaned before and after a dressing change, and mechanical lifts used for resident transfers were not disinfected between uses. Additionally, housekeeping staff sorted soiled laundry in the same room as clean laundry without wearing gowns, risking contamination.
A facility failed to accurately code a resident's MDS assessment, omitting hospice services despite the resident's serious medical conditions and prognosis. The error was confirmed by the facility's MDS coordinator, DON, and administrator, who acknowledged the need for accurate coding as per the facility's policy.
A resident with Parkinson's, dementia, and depression was not referred for a PASARR Level II evaluation after new diagnoses of anxiety and psychotic disorders. Facility staff were unaware of the process for Level II screenings, and the policy lacked guidance on referring residents with new mental health conditions.
A newly admitted resident, who was cognitively intact and required significant assistance, did not receive a copy of their baseline care plan despite attending a care conference. Facility staff confirmed that the care plan was not offered unless requested, contrary to policy stating residents have the right to review their care plan.
A resident with a stage four pressure ulcer on the coccyx was not repositioned or offloaded for nearly three hours, despite being dependent on staff for repositioning. The resident's care plan lacked specific interventions for repositioning, and staff interviews revealed a lack of adherence to the required repositioning schedule. The facility's pressure ulcer prevention policy was not adequately implemented.
Failure to Reposition and Toilet a Resident With a Stage 4 Sacral Pressure Ulcer
Penalty
Summary
The facility failed to provide timely repositioning and toileting for a resident with a stage 4 pressure ulcer on the sacral region who was dependent on staff for all ADLs, was always incontinent of bowel and bladder, and had severe cognitive impairment. The resident’s records showed she was at risk for skin breakdown related to decreased mobility, inability to change or shift positions, incontinence, previous pressure ulcer, and poor nutrition. Her care plan and physician orders directed that she be turned and repositioned at least every two hours, be encouraged to lie down between meals, and receive extensive assistance for toileting and repositioning. On 8/19/25, continuous observation showed the resident remained in her wheelchair for extended periods while attending breakfast, bible study, an activity, and lunch, and she was not checked, changed, or repositioned for more than four hours. At 1:00 p.m., nursing assistants assisted her to bed via mechanical lift and removed an adult diaper that was described as pretty wet and significantly expanded. The resident’s buttocks were noted to be red from sitting so long, with many skin creases, and the nursing assistant stated the last diaper change and repositioning had been about 8:00 a.m. that morning. The nursing assistant also stated the resident needed special care because of the wound and should be offloaded every two hours. The DON reviewed camera footage and confirmed staff had not changed or repositioned the resident for more than four hours. The DON stated there were no behaviors or refusals of care and that staff had opportunities to return the resident to her room after chapel or before or during an activity to change and offload her before lunch. The resident’s sacral wound had fluctuated in size across wound provider visits, and on the day of observation the DON described the ulcer as circular and about the size of a D battery. The facility’s pressure ulcer policies stated residents with pressure ulcers should receive treatment and services to promote healing and prevent new pressure ulcers, and that residents with repositioning orders should have a will return clock on the door to indicate the turning schedule.
Unsafe Resident Bathroom Water Temperatures
Penalty
Summary
The facility failed to ensure safe and appropriate water temperatures were maintained below 120 degrees Fahrenheit in resident bathrooms. During observation and interview, the bathroom faucet water in R37’s room felt excessively hot, and R37 stated he used the bathroom independently and did not report the issue because other residents complained the water was not hot enough. R37’s records showed a diagnosis of Parkinson’s disease, intact cognition, and use of a wheelchair and walker, with care plans indicating extensive assistance with toileting and personal hygiene. In R28’s room, the bathroom faucet water also felt excessively hot during observation, and R28 stated the water got pretty hot but she had not burned herself. R28’s records showed chronic kidney disease, intact cognition, and use of a walker and wheelchair, with care plans indicating independence with personal hygiene and toileting. The director of environmental services measured the water temperature at R37’s bathroom faucet at 121.8 degrees Fahrenheit and at R28’s bathroom faucet at 121.3 degrees Fahrenheit. He stated he tried to keep temperatures between 115 and 118 degrees Fahrenheit and was aware resident bathroom water should not exceed 120 degrees Fahrenheit due to potential for scalding. He also stated he did not regularly check or document water temperatures, only checking when water seemed too hot or staff reported it, and that all bathroom faucet temperatures in that hallway would be the same because the water came from the same location. A trained medication aide confirmed both residents used their bathrooms independently.
Failure to Use Required PPE During Wound Care
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when the facility failed to ensure PPE was used for one resident with pressure ulcers. The resident’s admission MDS indicated severe cognitive impairment, one stage 2 pressure ulcer present on admission, four additional stage 2 pressure ulcers present on admission, and diagnoses that included open wounds of the left foot, left lower leg, and left buttock. The care plan revised 6/12/25 identified impaired skin integrity related to decreased mobility, poor nutrition, and current wounds, with complete wound care as ordered. On 8/19/25 at 11:05 a.m., no signage was posted to show the resident was on enhanced barrier precautions, and an RN and NA were in the room wearing gloves but not gowns. The RN rolled the resident side to side in bed, completed wound care to the buttocks wound, and applied a dressing, while the NA completed the brief change. Both staff removed gloves and disinfected hands before leaving the room. The NA stated she had asked the DON whether gowns were required and was told the resident’s wound did not meet the requirements for additional PPE beyond gloves. The RN stated the resident was not on EBP that required a gown during dressing change. The DON, who also served as the infection preventionist, stated the facility’s EBP policy applies to residents with catheters, central lines, wound vacuums, or wounds with depth/tunneling, acknowledged misinterpreting the EBP guidelines, and confirmed the resident had chronic pressure wounds and should have been on EBP.
Infection Control Breach in Dietary Services
Penalty
Summary
The facility failed to ensure that dietary staff adhered to proper infection control practices during food service in the dining room, potentially affecting all 47 residents. Observations revealed that dietary aides were handling cups by the rim with bare hands while filling and serving beverages. Specifically, on multiple occasions, dietary aides were seen holding the rims of plastic tumblers and a thermal coffee mug when placing them on tables for residents. Interviews with the dietary manager and the involved dietary aides confirmed that the staff had received training on the correct method of handling cups to prevent contamination. Despite this training, the aides acknowledged their improper handling of the cups, which was contrary to the facility's policy on dish and utensil handling. The policy, signed by the aides, explicitly stated that fingers should not be placed on the lip or contact surfaces of cups and glasses.
Infection Control Deficiencies in Wound Care, Equipment Cleaning, and Laundry Handling
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during the care of a resident with a pressure ulcer. The resident, who was cognitively intact and required substantial assistance with activities of daily living, had a stage four pressure ulcer on the coccyx. During a dressing change, an LPN used the resident's overbed table as a work surface without cleaning or disinfecting it, nor did she use a barrier between the table and the supplies. The LPN also failed to remove the resident's personal items from the table before using it for the dressing change. After the procedure, the table was not cleaned before the resident's breakfast tray was placed on it, as evidenced by multiple water rings on the surface. The facility also did not ensure that mechanical transfer lifts were cleaned after use with residents. Two residents, one with hemiplegia and the other with dementia, required mechanical lifts for transfers. Observations revealed that nursing assistants did not disinfect the lifts immediately after use, despite the facility's policy requiring such cleaning to prevent the spread of infection. The DON confirmed that mechanical lifts are shared among multiple residents and should be cleaned between uses. Additionally, the facility's laundry practices were found to be inadequate. Housekeeping staff were observed sorting soiled laundry in the same room as clean laundry without wearing gowns, which could lead to contamination. The environmental services director confirmed that laundry staff do not wear gowns when sorting soiled laundry, and the DON acknowledged that soiled laundry should be sorted in a separate room to prevent infection spread. The facility's infection prevention and control manual directs staff to wear gowns if gross soiling of uniforms is likely.
Inaccurate MDS Assessment for Hospice Resident
Penalty
Summary
The facility failed to ensure that a resident's status was accurately identified in the Minimum Data Set (MDS) assessment. The resident, who had medical diagnoses of malignant neoplasm of the colon, malignant neoplasm of the tail of the pancreas, and mild intellectual disability, was receiving hospice services. However, the significant change MDS assessment did not mention hospice services under section O, despite indicating a prognosis of conditions or chronic diseases that may result in a life expectancy of less than six months. This discrepancy was confirmed during an interview with the registered nurse who is the facility MDS coordinator, as well as the director of nursing and the administrator, who acknowledged that the MDS should have been coded accurately. The facility's MDS Accuracy Policy from March 2019 states that the RAI Manual should be utilized for accurate coding, and any coding errors should be investigated and modified.
Failure to Complete PASARR Level II Referral for Resident with New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure a pre-admission screening and resident review (PASARR) Level II referral was completed upon a significant change in condition for a resident diagnosed with Parkinson's, dementia, and depression. Initially, the resident was not considered to have a serious mental illness or intellectual disability. However, the resident later received new diagnoses of anxiety disorder and psychotic disorder with hallucinations. Despite these changes, the facility did not notify the State Mental Health Agency for further evaluation and determination of the need for specialized services. Interviews with facility staff revealed a lack of understanding and process for conducting Level II screenings. The social services designee was unsure of the process for Level II screening, and the director of nursing admitted there was no process in place to ensure residents with new qualifying mental illness diagnoses would receive a Level II screening. The administrator also acknowledged the facility's lack of knowledge regarding when a Level II screening would be required. The facility's preadmission screening policy did not address the referral process for residents exhibiting new or possible serious mental disorders.
Failure to Provide Baseline Care Plan to Resident
Penalty
Summary
The facility failed to provide a summary of the baseline care plan to a newly admitted resident, identified as R26, who was cognitively intact and required substantial assistance with activities of daily living. R26 was admitted with diagnoses including sepsis, cerebral infarction, and type 2 diabetes mellitus, and was receiving insulin, antidepressant, antibiotic, and antiplatelet medications. Despite attending a care conference where the care plan was discussed, R26 reported not receiving a copy of the baseline care plan and expressed a desire to have one to share with family. Interviews with facility staff, including the social worker, director of nursing, and assistant director of nursing, confirmed that the baseline care plan was not offered to R26 or their family unless specifically requested. The facility's policy stated that residents have the right to review and participate in their care plan, but it was unclear who was responsible for ensuring the resident received a copy. This oversight led to the deficiency identified in the report.
Failure to Reposition Resident with Pressure Ulcer
Penalty
Summary
The facility failed to provide timely repositioning for a resident who was dependent on staff for repositioning and had a pressure ulcer on her coccyx. The resident, who was cognitively intact and required substantial assistance with most activities of daily living, was observed to have a stage four pressure ulcer that was healing. Despite being at risk for skin breakdown due to immobility and urinary incontinence, the resident did not have a turning or repositioning program in place. During a continuous observation period, the resident was not repositioned or offloaded for nearly three hours while seated in a wheelchair, contrary to physician orders that required repositioning every two hours. Interviews with staff revealed a lack of awareness and adherence to the repositioning schedule. A nursing assistant could not specify when the resident was last repositioned, and a licensed practical nurse acknowledged that the resident had not been laid down that morning. The director of nursing was unaware of the failure to reposition the resident and expected staff to follow the physician's orders. The facility's pressure ulcer prevention policy indicated that residents with pressure ulcers should receive necessary treatment and services to promote healing, but this was not adequately implemented for the resident in question.
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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 Mapleton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Laurels Peak Care & Rehabilitation Center | 15.2 mi | ★★★★★ | 19 | 0 |
| Hillcrest Care & Rehabilitation Center | 16.1 mi | ★★★★★ | 5 | 0 |
| Oaklawn Care & Rehabilitation Center | 16.4 mi | ★★★★★ | 2 | 0 |
| Pathstone Living | 16.7 mi | ★★★★★ | 25 | 0 |
| Parkview Care Center | 17.7 mi | ★★★★★ | 12 | 0 |
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