Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 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.
MDS assessments failed to accurately capture residents’ fall histories for two residents. One resident with impaired cognition, a wheelchair, and a documented history of falls had multiple falls in progress notes, but the MDS undercounted the events. Another resident with dementia, a walker, and repeated falls had four documented falls during the look-back period, yet the MDS coded fewer falls than occurred. The ADON confirmed the coding errors and stated paper charting may have contributed to missed falls during MDS review.
Failure to Update Care Plans With New Fall Interventions: The facility did not add resident-specific fall interventions to the comprehensive care plans for three residents with repeated falls. Although accident reports and IDT reviews identified new interventions for each resident, staff said the changes were often shared in report or email and the DON confirmed they were not incorporated into the care plans. The residents had histories of falls, impaired cognition or dementia-related diagnoses, and used mobility aids such as walkers or wheelchairs.
Incomplete assessment of new bruises and abrasions: A resident with severely impaired cognition, dementia, a recent hip fracture/repair, and anticoagulant use had new bruises and abrasions documented on admission and during weekly skin checks, but the RN and LPN notes lacked comprehensive descriptions such as bruise size, shape, dimensions, and color. An RN also documented a new bruise and completed an incident report without a focused assessment, and the DON stated staff were not completing comprehensive, descriptive assessments of new non-pressure skin conditions.
Fall interventions identified after resident falls were not added to care plans for three residents. A resident with repeated falls, dementia, and walker use had multiple post-fall interventions documented on accident reports, but they were kept on paper forms or passed by word of mouth instead of being available in the care plan. Two other residents with impaired cognition and fall histories had similar post-fall interventions documented, including equipment changes, medication changes, and supervision-related measures, but staff and the DON confirmed these interventions were not readily available to all staff through the care plan.
The facility failed to use EBP and contact precautions correctly during resident care. Two residents with wounds requiring dressing changes did not have gown use during wound care, despite documentation and staff statements indicating EBP was expected. In addition, a resident on contact precautions for VRE in urine received toileting assistance from a TMA who wore gloves but no gown, even though signage and a PPE cart were posted outside the room.
Failure to Offer Recommended Pneumococcal Vaccination Updates: The DON, pharmacy, and nursing staff did not ensure two residents were offered pneumococcal vaccine updates based on CDC PneumoRecs guidance. One resident with dementia, CKD, CHF, and COPD had prior PPSV23 and was not offered the recommended PCV update during short-term rehab before moving to LTC status; another resident with hepatic encephalopathy and NASH had prior PPSV23 and PCV13 but was also not offered the recommended PCV20/PCV21 update. Both residents stated they would have accepted vaccines if offered.
The facility failed to ensure daily nursing staffing postings were accurately completed and posted. Review of staffing sheets showed multiple blank shifts across several months and several dates with no RN identified, including shifts worked by agency nurses. The DON stated charge nurses were responsible for completing the form each shift, but she did not monitor the process, and staff interviews showed inconsistent understanding of who completed the posting.
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.
MDS assessments did not accurately reflect residents’ fall histories
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected residents’ fall histories for 2 of 3 residents reviewed for falls. One resident had impaired cognition, no behaviors or rejection of care, used a wheelchair, and had diagnoses including non-traumatic brain dysfunction, high blood pressure, and Alzheimer’s disease. The resident’s care plan identified a fall risk related to poor balance, assistive devices for mobility, psychotropic medication use, and a history of falls. Facility progress notes documented multiple falls over time, but the resident’s quarterly MDS and significant change MDS each underreported the number of falls that occurred during the applicable look-back periods. Another resident’s quarterly MDS indicated no cognitive impairment, use of a walker, independence with walking, and diagnoses including non-Alzheimer’s dementia, repeated falls, and chronic pain. The MDS coded only one fall with no injury and one fall with injury except major, while accident reports showed four falls during the look-back period, including two falls with injury except major and two falls with no injury. The ADON, who completed the MDS assessments, confirmed the fall coding was incorrect and stated the facility did not use its electronic record system to its full potential, with much charting still on paper, which could result in falls being missed when reviewing for assessments. The DON stated the MDS was expected to accurately reflect residents’ falls, and the facility’s MDS Accuracy Policy required use of the RAI Manual to ensure accuracy in all coding areas.
Failure to Update Care Plans With New Fall Interventions
Penalty
Summary
The facility failed to revise and update the comprehensive care plans for residents with repeated falls to include new fall interventions identified after each incident. For R10, the quarterly MDS showed no cognitive impairment, use of a walker, independent walking, diagnoses including Non-Alzheimer's Dementia, repeated falls, and chronic pain. R10's care plan identified her as a fall risk and included general interventions such as keeping the call light within reach and following the facility fall protocol, but it did not include multiple later interventions developed after subsequent falls. R10 had several falls with specific interventions identified through accident reports and interdisciplinary team review, including reminders to have staff retrieve items from the floor, using a chair when playing cards, calling staff for transfers and incontinent care, evaluating a wider bed and installing a grab bar, developing a smoking contract or revoking smoking privileges, and encouraging her to slow down and stop if lightheaded. Review of the comprehensive care plan showed that the interventions developed after the falls on 2/14/26, 3/11/26, 3/24/26, 4/30/26, and 6/8/26 were not added. Staff interviews confirmed that the new interventions were communicated in report or email, but were not documented in the care plan, and the DON acknowledged the paper investigation forms were kept in her office and were not readily available to staff. Similar omissions were identified for R2 and R3. R2's MDS showed impaired cognition, wheelchair use, and a history of falls, and the care plan included general fall precautions, but accident reports documented multiple falls with interventions such as a wide bed, clipping the call light to the chest, a fall mat, hospice referral, medication changes, removing or flipping out a foot pedal, and discontinuing a medication after concern for adverse effects. R3's MDS showed impaired cognition, wheeled walker use, and a history of falls, and the care plan included general fall precautions, but accident reports documented interventions such as decreasing medication, reminding the resident to wear shoes in the room and letting staff carry large items, and moving the resident closer to the nurses' station with medication discontinued. The DON confirmed these interventions were not added to the comprehensive care plans, and staff stated they relied on the care plan or report for current resident-specific fall interventions.
Incomplete assessment of new bruises and abrasions
Penalty
Summary
The facility failed to comprehensively assess new bruises and abrasions for a resident with severely impaired cognition, arthritis, dementia, a recent hip fracture and repair, and anticoagulant use. The resident’s significant change MDS and care plan indicated a need for weekly skin inspections and monitoring for redness, open areas, scratches, cuts, and bruises, with reporting of changes to the nurse. On admission/readmission, the RN documented skin issues including bruising from hospitalization, coccyx redness, and a surgical incision, but did not include bruise size, shape, dimensions, or color, and the assessment did not include an intervention to monitor, document, or report signs or symptoms of anticoagulant complications such as bruising. Subsequent weekly skin checks documented a bruising-related fall, a new abrasion to the left forearm, redness to the right knee, and later a new bruise of unknown origin measuring 3 cm by 2 cm on the left knee/rear, but the assessments did not provide further descriptive information about the skin findings. An incident report also noted a new bruise to the back of the left leg below the knee with no redness, warmth, swelling, or pain with walking, and Tylenol helping, but again lacked additional description. During interview, the RN stated she was unsure whether a focused assessment should have been completed and was unsure how other nurses would tell if the bruise was worsening or healing. The DON stated she was unaware nurses were not completing comprehensive, descriptive assessments of new non-pressure skin conditions and that the incident form was thought to cover everything.
Fall interventions were not incorporated into care plans
Penalty
Summary
The facility failed to ensure that fall-related interventions were incorporated into residents’ care plans and made available to staff for 3 of 3 residents reviewed for accidents (R2, R3, and R10). The report states that after falls, interdisciplinary team reviews identified specific interventions, but those interventions were kept on paper accident investigation forms in the DON’s office or communicated by word of mouth rather than being added to the comprehensive care plans. Multiple staff members stated they relied on the care plan to know the current fall-prevention measures, and the DON confirmed staff would not have a readily available method to identify the residents’ current fall interventions. R10’s records showed a history of repeated falls, use of a walker, chronic pain, and non-Alzheimer’s dementia. After several falls, the interdisciplinary team identified interventions such as reminding R10 to have staff retrieve items from the floor, using a chair when playing cards, calling staff for assistance with transfers and incontinent care, installing a grab bar, developing a smoking contract or revoking smoking privileges, and encouraging her to slow down and stop if lightheaded. The report states that the interventions from multiple falls, including those from 2/14/26, 3/24/26, 4/30/26, and 6/8/26, were not present on the care plan. Staff interviews confirmed they were not aware of all interventions in place to prevent further falls. R2 had impaired cognition, used a wheelchair, and had a history of falls, with additional falls documented in progress notes and accident reports. Interdisciplinary team interventions included a wide bed, clipping the call light to the chest, a fall mat at bedside, hospice referral, medication changes, removing or flipping out a foot pedal, and discontinuing an anxiety medication. R3 had impaired cognition, used a wheeled walker, and had a history of falls and a hip fracture. Interdisciplinary team interventions included decreasing medication, reminding the resident to wear shoes and letting staff carry large items, moving the resident closer to nurses, and discontinuing medication. Staff and the DON confirmed these interventions were passed in report or kept in a binder rather than being available on the residents’ care plans.
Failure to Use EBP and Contact Precautions During Resident Care
Penalty
Summary
The facility failed to implement infection prevention and control practices by not using Enhanced Barrier Precautions (EBP), including gown and glove use, during wound care for two residents with skin conditions. One resident had bilateral lower leg blisters and a physician’s order for cleansing, moisturizing, and dressing the lower extremities, with provider documentation noting a right lower extremity blister with drainage and tenderness. During observation, no EBP signage or PPE was present outside the resident’s room, and the LPN who completed the wound care stated she wore gloves but did not wear a gown and was not aware EBP was required. A second resident had diagnoses including dementia and cellulitis of the left lower limb, with care plan documentation for impaired skin integrity and wound care orders for two open ulcers requiring daily cleansing, topical treatment, and dressing changes. The resident stated nursing staff performed dressing changes with gloves but no gowns, and observation of the room showed no EBP signage or PPE cart outside the room. During wound care observation, the RN wore gloves and performed hand hygiene but did not wear a gown, and stated the resident would be expected to be on EBP because of the wound requiring dressing changes. The facility also failed to follow transmission-based contact precautions for a resident on contact precautions for VRE in urine. The resident’s care plan and TAR indicated contact precautions with gown and glove use when entering the room, and observation showed signage and a PPE cart outside the room. However, during toileting assistance, the TMA wore gloves but no gown and exited the bathroom without a gown. The DON confirmed the resident was on contact precautions for VRE in urine and stated staff should know to use gown and gloves during toileting assistance because of the posted signage and PPE cart.
Failure to Offer Recommended Pneumococcal Vaccination Updates
Penalty
Summary
The facility failed to offer recommended pneumococcal immunization updates for 2 of 5 residents reviewed for immunizations. One resident had diagnoses including dementia, chronic kidney disease, congestive heart failure, and chronic obstructive pulmonary disease, and his vaccine history showed receipt of PPSV23 in 2011. PneumoRecs VaxAdvisor recommended one dose of PCV15, PCV20, or PCV21 at least one year after the last PPSV23 dose, but the resident’s physician orders did not include vaccinations and the facility did not offer the update while he was in short-term rehabilitation; the DON stated the resident later moved to LTC status and missed the vaccine clinic held in April, with the next clinic planned for the end of July. The resident’s family member stated she could not recall the facility discussing additional vaccinations, but would have agreed if one had been recommended. The second resident had diagnoses of hepatic encephalopathy and nonalcoholic steatohepatitis, with moderately impaired cognition and substantial assistance or dependence for ADLs. Her vaccine history showed PPSV23 in 2017 and PCV13 in 2020, and PneumoRecs VaxAdvisor recommended one dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose. Her physician orders did not include vaccines, and she stated no vaccines had been offered or received since admission, though she would have accepted them if recommended. The DON stated vaccines would be recommended at the end of the resident’s short-term stay, and staff interviews showed immunization review was handled by the DON and pharmacy during vaccine clinics rather than by nursing staff assessing eligibility on admission.
Incomplete Nursing Staffing Postings
Penalty
Summary
The facility failed to ensure required and accurate nursing staffing information was posted each day. During observation, the daily nursing staffing posting at the nurses station included the required categories for RN, LPN, TMA, and CNA, but review of postings for April through June showed multiple blank shifts and missing RN documentation. In April, 16 shifts were left blank, all on night shift, and an RN was not identified on five dates. In May, 12 shifts were left blank, including 16 night shifts and one evening shift, and on one date an RN in training was listed without another RN identified. In June, 16 shifts were left blank, including night, evening, and day shifts, and an RN was not identified on four dates. The DON stated charge nurses were responsible for completing the staffing posting at the start of each shift and that at least one RN was scheduled for eight consecutive hours every day, with a nurse leader scheduled on day shift Monday through Friday. The DON said the missing RN entries were primarily on shifts worked by agency nurses who likely did not know they needed to complete the form, and stated she did not monitor the process to ensure the form was completed each shift and each day. RN-A stated she had never filled out a staffing posting for a shift she worked, while LPN-A stated the charge nurse completed the posting using the electronic schedule and updated it for call-ins. The facility policy stated the charge nurse was to obtain and complete the staffing hours form on each shift.
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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What surveyors actually found near you
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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 Health Care, Llc | 15.2 mi | ★★★★★ | 1 | 0 |
| Hillcrest Health Care, Llc | 16.1 mi | ★★★★★ | 6 | 0 |
| Oaklawn Health Care, Llc | 16.4 mi | ★★★★★ | 11 | 0 |
| Pathstone Living | 16.7 mi | ★★★★★ | 25 | 0 |
| Parkview Care Center | 17.7 mi | ★★★★★ | 12 | 0 |
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