Below average — CMS composite of the measures below.
The next survey window likely opens 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 Maplewood Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to include individualized care plan problems, goals, and interventions for three residents receiving antiplatelet or anticoagulant medications, despite physician orders and TAR entries documenting blood‑thinner use and monitoring. Residents on clopidogrel with aspirin, apixaban, and enoxaparin had admission MDS assessments indicating antiplatelet or anticoagulant therapy, but their comprehensive care plans, Kardexes, and care guides did not identify bleeding risk or blood‑thinner use. One resident reported daily abdominal injections and bruising at the injection site. An NA stated she relies on care guides and the Kardex, which did not show blood‑thinner use, and needed to ask a nurse for this information. An LPN indicated such risks should be care planned, while the clinical care coordinator and DON either were unaware of or could not explain the need to address high‑risk medications in care plans. The facility’s care planning policy lacked specific guidance on identifying and care planning for high‑risk medications and administration routes.
QAPI did not show ongoing monitoring, tracking, or audits after repeat citations for provider notification, care plan revision, hearing services, oxygen use, and infection control. Surveyors found failures to notify the provider about a toenail infection, refused podiatry appointments, delayed notification of diarrhea and weight gain changes, inaccurate care plans for multiple residents, no available audiology appointment for a resident requesting services, oxygen given without a provider order, and improper infection control practices with a central line.
Failure to provide toenail care for a dependent resident with severe cognitive impairment and multiple diagnoses. Facility documentation showed nail care was charted on bath/shower days, but staff did not identify any toenail concerns before discharge. After transfer to a group home, the guardian noted the resident’s toenails were yellow, thick, and nearly falling off, and the resident was sent to the ER where a provider documented a bad toenail infection and fungal infection of the toenails. The DON and ADON later acknowledged the nails appeared overgrown and thick and could not have been done recently as charted.
Failure to Implement Ordered ROM Exercises: The facility did not carry out prescribed ROM exercises for multiple residents with active functional maintenance programs. Records showed no documentation that the ordered AAROM or PROM exercises were completed, and staff interviews confirmed nursing staff were unaware of the programs because they were not pulled into point-of-care documentation. Residents reviewed included individuals with stroke-related hemiplegia, MS, dementia, heart failure, cancer, and other chronic conditions, and the DON and ADON acknowledged the exercises were not being implemented as ordered.
A resident with moderate cognitive impairment and an indwelling urinary catheter was observed lying in bed with the door open while the catheter drainage bag was hanging uncovered on the side of the bed and visible to other residents, visitors, and staff. Nursing staff, the ADON, and the DON stated catheter bags should be covered to protect privacy and dignity, and staff confirmed the bag was not covered.
Call light not kept within reach. A resident with severe cognitive impairment, wheelchair use, total dependence for many ADLs, and a care plan directing staff to keep the call light within reach was repeatedly observed without the call light accessible; it was found on the floor and under a roommate's bed. Staff walked past the room without giving the resident the call light, and an NA, LPNs, and the DON all stated the call light should be within reach and secured with a clip.
Failure to Notify Provider and Representative of Changes in Condition: The facility did not notify the resident’s guardian or provider about severe toenail problems and refused podiatry visits for a resident with significant cognitive impairment, and the resident later required ER treatment for a fungal toenail infection. The facility also failed to notify the provider about ongoing diarrhea in one resident and repeated weight gains above ordered notification thresholds in another resident. Staff interviews and record review showed the changes were documented, but provider notification was not.
A resident’s confidential medical information was left visible on an unattended laptop mounted on a med cart in a hallway, where the screen displayed the resident’s full name, DOB, medication list, and diagnoses. RN confirmed the EMR was open and the information was confidential, and the DON acknowledged that leaving resident information exposed in a public area was not consistent with privacy expectations.
Dirty Resident Room Floors: Two residents’ room floors were repeatedly observed with accumulated dust, darkened residue, and debris beneath the bed and bedside table, with no evidence of recent cleaning. One resident had intact cognition and multiple chronic conditions including HF, schizophrenia, and prior thromboembolic disease; the other had moderate cognitive impairment and diagnoses including stroke, hemiplegia, renal failure, diabetes, COPD, and immunodeficiency. The HSK-A acknowledged the floors were not in a clean condition, and the DON stated resident rooms were expected to be maintained in a clean and sanitary condition at all times.
MDS Incorrectly Coded Anticoagulant Status: The facility failed to accurately code a resident’s MDS for anticoagulant status. The resident had a history of stroke, CAD, and HTN, and the MAR showed clopidogrel, an antiplatelet, but no anticoagulant was administered. The MDS nurse stated the resident was on clopidogrel and did not receive an anticoagulant, while the DON said clopidogrel was mistakenly treated as an anticoagulant during coding.
Care plans were not accurately developed or revised for three residents. One resident with heart failure and lower-extremity edema had ACE wraps ordered for edema management, but the care plan did not include that intervention. Another resident’s care plan still listed EBP after the precautions had been discontinued. A third resident’s care plan contained conflicting directions about eating assistance, with staff giving inconsistent descriptions of the resident’s actual needs.
A resident with moderate cognitive impairment and multiple medical diagnoses, including dementia and an indwelling urinary catheter, was repeatedly observed wearing the same visibly soiled clothing across the survey period. Staff confirmed the resident needed assistance with dressing or changing dirty clothes, and the DON stated residents were expected to be dressed in clean clothing daily, but the resident remained in stained clothing throughout the observations.
A resident with intact cognition and multiple diagnoses, including hemiplegia, DM, bipolar disorder, dysphagia, and malnutrition, remained in bed with the room dark and no activity materials present. Staff did not routinely offer activities unless requested, no individualized or group activities were observed, and the activity record showed no documentation of participation or refusal. The AA acknowledged one-to-one activities were not occurring due to low staffing, and the DON confirmed the resident remaining in bed without activities being offered was not consistent with facility expectations.
A resident with Parkinson's disease, dementia, and depression repeatedly requested audiology services, but the facility had no record that she was ever seen by audiology. Staff and family reported she had hearing difficulty, needed others to speak closely or into her ear, and did not wear hearing aids. Interviews showed HealthDrive had no audiologist available, no outside audiology appointment had been arranged, and the resident remained on a list without documented follow-through.
Failure to administer or properly document UTI prevention treatment for a resident with recurrent UTIs. A cognitively intact resident who was dependent for toileting and frequently incontinent had Estradiol Vaginal Cream ordered for UTI prevention, but the MAR showed repeated refusals and an RN documented a refusal before actually offering the medication. The resident said she had only been offered the medication once that she could remember, and the RN, NP, and DON all acknowledged that consistent refusals should be reported and that refusals should not be charted unless the treatment was offered.
A resident with a colostomy had active orders that did not clearly identify the correct pouch or barrier ring, and nursing documentation showed repeated pouch changes with limited assessment detail. The resident reported severe pain, raw and excoriated peristomal skin, and leakage with stool resting on the skin. An LPN stated the resident did not have the needed ring at one point and that stool was getting under the supplies, while the NP was not notified of earlier skin breakdown and the DON confirmed the orders lacked specific supply information.
A resident with intact cognition and multiple diagnoses, including stroke-related hemiplegia, dysphagia, and malnutrition, was observed receiving oxygen via nasal cannula on multiple occasions. Record review found no physician order authorizing oxygen therapy, no documented flow rate, route, or parameters, and staff, including an LPN, ADON, and DON, confirmed the resident was receiving continuous oxygen without an active order.
A facility failed to maintain accurate medical records for three residents. One resident’s MAR showed Estradiol refusals even though the RN had not offered the medication yet. Another resident with ESRD had TAR entries for bruit/thrill checks despite having an external dialysis port, and staff confirmed the assessment was not appropriate for that device. A third resident’s weekly skin checks documented toenail care as completed or not needed, but later the resident was found to have severely overgrown, infected toenails and was treated in the ER.
A resident with a central line, cognitive impairment, and significant functional dependence did not receive consistent infection control measures. The care plan and TAR showed EBP for the IV/central line, but the record lacked evidence of November dressing changes and the ordered PICC removal was not documented as completed. During observation, the dressing was old and curling, and staff provided hands-on care wearing gloves only, while interviews confirmed the central line was still present and EBP should have remained in place.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment presented risks that were not properly mitigated, and supervision was insufficient to ensure resident safety.
The facility failed to implement Enhanced Barrier Precautions (EBP) and proper use of PPE during high-contact resident care activities, such as IV antibiotic administration and wound care. Additionally, hand hygiene practices were not followed, and shared equipment was not disinfected between uses. Reusable ice packs were improperly stored with resident food, violating infection control protocols.
A facility failed to clean the ceiling exhaust fan in a third-floor shower room, affecting residents using the room. Observations showed the vent was covered in gray debris, and interviews with staff revealed confusion over cleaning responsibilities. Maintenance and housekeeping staff had differing accounts of cleaning routines, and the facility lacked a clear policy or checklist for daily cleaning.
A resident with intact cognition was not included in healthcare decisions, as the facility continued to involve a family member as power of attorney without the resident's consent. Despite the resident's expressed desire to change the power of attorney, the facility did not facilitate this change or include the resident in care conferences.
A resident with diabetes, hypertension, and congestive heart failure experienced new vision loss, but the facility failed to notify the physician or schedule an urgent appointment with a retinal specialist as recommended. Despite the resident's complaints and visible eye irritation, staff did not assess or document the condition properly. The facility's policy on change in condition notification was not followed, leading to a delay in addressing the resident's vision issues.
A facility failed to include a swallow study referral in a resident's discharge plan, despite recommendations from the SLP due to dysphagia. The resident, with multiple medical conditions, was discharged without arrangements for the study, and staff interviews revealed a lack of communication and coordination. The facility's discharge planning policy was not effectively executed, leading to a deficiency in meeting the resident's post-discharge needs.
A resident with diabetes and hypertension experienced vision loss due to the facility's failure to schedule a timely appointment with a retinal specialist, despite urgent recommendations. The resident reported symptoms for weeks, but the nursing staff did not assess or document the condition, and the Health Information Manager missed the urgency in the follow-up instructions.
Two residents at the facility were not offered or provided updated pneumococcal vaccinations as per CDC guidelines. One resident, with a history of chronic conditions, had consented to additional vaccines, but there was no documentation of shared clinical decision-making. Another resident's vaccine history was unclear, and there was no follow-up on her vaccination status. The DON admitted to not reviewing vaccines per updated CDC recommendations and failing to verify the second resident's vaccine history.
A resident with intact cognition was not invited to participate in care conferences, despite being capable of making her own healthcare decisions. The facility failed to document any refusal or impracticability of her participation, leading to a deficiency in care planning. Interviews revealed a lack of communication and adherence to policies regarding resident involvement in care planning.
A facility failed to adequately assess and supervise a resident for safe smoking practices, leading to safety hazards. The resident, who used intermittent oxygen therapy, had a history of smoking incidents, but the facility did not conduct timely assessments. Additionally, the facility did not address a safety hazard involving resident-to-resident abuse, where a resident with cognitive impairment and substance use history was involved in an altercation. The facility's failure to follow policies for smoking assessments and managing resident behavior contributed to the deficiencies.
A resident with pulmonary embolism and dyspnea did not have their oxygen tubing changed weekly as required, despite documentation indicating otherwise. Observations showed the tubing was dated 9/3, and staff interviews confirmed the lapse in maintenance and documentation accuracy. The facility lacked a specific policy on oxygen tubing but expected adherence to batch orders.
A resident with moderate cognitive impairment reported being raped at the facility to a family member over the phone, which was overheard by an NA and an LPN. Despite hearing the allegation, the LPN did not report it immediately, as required by facility policy and state regulations. The incident occurred on a Saturday evening, but the facility did not report it to the State Agency until the following Monday morning, exceeding the two-hour reporting requirement.
The facility failed to monitor edema and comprehensively assess non-pressure related wounds for a resident with multiple health conditions, including brain cancer, hypertension, and chronic ischemic heart disease, who was receiving hospice care. The documentation of edema and weight monitoring was inconsistent and lacked comprehensive details, and the resident's skin evaluations and wound assessments were found to be lacking. Interviews with staff revealed that the required monitoring and documentation were not adequately performed.
Failure to Care Plan for Residents on Blood-Thinning Medications
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive care plans addressing the use of blood‑thinning medications for three residents receiving antiplatelet or anticoagulant therapy. For one resident with a history of stroke and dysphagia who received clopidogrel via G‑tube and aspirin via J‑tube, the admission MDS documented antiplatelet use and the Treatment Administration Record (TAR) contained physician‑ordered monitoring related to blood‑thinning medications. However, the comprehensive care plan in effect at the time of survey did not identify any problem, goal, or interventions related to blood‑thinner use, did not identify the resident as being at risk for bleeding, and did not include interventions to manage or mitigate bleeding risk. The Kardex and requested care guide also did not identify the resident’s use of blood‑thinning medications. A second resident with atrial fibrillation had an admission MDS documenting anticoagulant use and a physician’s order for apixaban twice daily. The FDA‑approved labeling for apixaban notes increased risk of serious, potentially fatal bleeding and lists signs and symptoms of blood loss. The January TAR showed physician‑ordered monitoring interventions associated with blood‑thinning medications, but the comprehensive care plan did not include any problem, goal, or interventions related to anticoagulant therapy. This resident was not identified in the care plan as being at risk for bleeding, and there were no individualized interventions addressing management or mitigation of bleeding risk. The Kardex did not identify the resident’s use of blood‑thinning medications, and the requested care guide was not provided. A third resident with an infection and inflammatory reaction due to an internal joint prosthesis of the left knee had an admission MDS documenting anticoagulant use and a physician’s order for daily enoxaparin injections. The FDA‑approved labeling for enoxaparin states it should be used with extreme caution in conditions with increased risk of hemorrhage. The January TAR again showed physician‑ordered monitoring interventions related to blood‑thinning medications, but the comprehensive care plan did not identify any problem, goal, or interventions related to anticoagulant therapy or bleeding risk. The Kardex and an undated care guide did not identify the resident’s use of blood‑thinning medications. During interview, this resident reported receiving a daily blood‑thinner injection in the abdomen and experiencing bruising at the injection site. Staff interviews revealed that NAs rely on care guides and Kardexes, which did not list blood‑thinner use, and that the nurse manager and DON were unaware or unable to explain the need to address blood‑thinning medications and associated bleeding risk in the care plans. The facility’s care planning policy lacked specific guidance requiring identification and care planning of high‑risk medications and routes, and therefore did not ensure foreseeable risks such as bleeding from blood‑thinning medications were addressed through individualized care plan interventions.
QAPI Program Failed to Sustain Compliance With Repeat Deficiencies
Penalty
Summary
The facility failed to sustain ongoing compliance through its QAPI program related to repeat deficiencies from prior surveys, including provider notification of changes, care plan revisions, hearing appointment arrangements, oxygen administration, and infection control practices. Review of the CASPER-3 report dated 11/25/25 showed prior citations for F580, F657, F685, F695, and F880 from earlier surveys, and the facility’s QAPI committee meeting minutes dated 11/11/25 lacked evidence of ongoing monitoring, tracking, or audits to ensure continued compliance after the previous recertification survey. During interview, the regional operations director stated the expectation was for QAPI to continue through audits, spot checks, and mock surveys. Specific findings included failure to notify the provider and resident representative about a toenail infection and refused podiatry appointments for one resident who required podiatry services. The facility also failed to promptly notify the physician or practitioner of episodes of diarrhea for one resident reviewed for constipation and failed to notify the provider of significant weight gain within ordered parameters for another resident. In addition, care plans for three residents were not accurately developed, implemented, or revised to reflect current needs, including missing edema interventions, not removing discontinued enhanced barrier precautions, and conflicting information about eating assistance. The facility also failed to ensure an audiology appointment was available for one resident requesting audiology services, administered oxygen therapy without a physician’s order for one resident, and failed to maintain appropriate infection control measures for a resident with a central line, including dressing changes and use of enhanced barrier precautions with PPE.
Failure to Provide Toenail Care for a Dependent Resident
Penalty
Summary
The facility failed to ensure toenail care was completed for a resident who was dependent on staff for activities of daily living, including lower body dressing and clothing management. The resident had severe cognitive impairment and diagnoses of intellectual disabilities, seizure disorder, and personality disorder. Facility records showed weekly skin inspections documenting toenail care on some dates and stating on other dates that the toenails did not require trimming. Staff interviews indicated nail care was completed on bath or shower days, with nurses responsible if the resident was diabetic or if there were concerns, but no staff member recalled any toenail concerns for the resident before the deficiency was identified. After the resident discharged to a group home, the guardian reported the toenails were in terrible shape, yellow, and appeared to be falling off. The resident was sent to the emergency room, where the provider documented a bad toenail infection, significant thickening and discoloration of all toenails, red non-blanching papules on both feet, and a diagnosis of fungal infection of the toenails. The assistant director of nursing reviewed pictures of the nails and verified they looked overgrown, yellow, and thick, and stated they could not have been done recently as documented. The guardian stated the facility had never discussed the toenail issue, and the provider at the group home stated the condition appeared to have been present for a few months.
Failure to Implement Ordered ROM Exercises
Penalty
Summary
The facility failed to ensure residents received prescribed range of motion (ROM) exercises in accordance with their functional maintenance programs for 7 of 7 residents reviewed. The report states that the facility did not implement the ROM exercises outlined in the residents’ functional maintenance programs and did not have a policy or procedure to ensure those programs were implemented, communicated to direct care staff, and consistently monitored for completion. For one resident with hemiplegia and hemiparesis following a cerebral infarction, muscle weakness, acute respiratory failure with hypoxia, gout, and morbid obesity with alveolar hypoventilation, the quarterly MDS showed cognitive intactness and significant assistance needs with ADLs and transfers. OT ordered active assistive ROM to both upper extremities, and the care plan included passive ROM to both hips, knees, and ankles. However, the TAR lacked functional maintenance documentation and a schedule for completion, and the resident stated staff were supposed to help but did not. Observation and staff interviews confirmed ROM was not completed, and the DON stated the facility had discovered the functional maintenance program was not getting done because it was not automatically populating into other documentation areas. For the other six residents reviewed, each had an active functional maintenance program with scheduled ROM exercises, but review of therapy documentation and nursing notes showed no documentation that the exercises were carried out as prescribed. These residents included individuals with severe cognitive impairment, moderate cognitive impairment, intact cognition, stroke-related hemiplegia, multiple sclerosis, heart failure, schizophrenia, renal failure, cancer, and other chronic conditions. For each of these residents, the record lacked documentation of refusal, contraindications, or physician notification related to the missed ROM. Interviews with nursing assistants and nursing leadership confirmed staff were unaware of the programs because the functional maintenance programs had not been pulled into point-of-care documentation, and the interim Administrator stated the facility did not have a generalized mobility policy.
Uncovered Catheter Bag Visible to Others
Penalty
Summary
The facility failed to maintain a resident's privacy and dignity by leaving an indwelling urinary catheter drainage bag exposed to public view. The resident had moderate cognitive impairment and required assistance with ADLs, with diagnoses including cancer, anemia, hypertension, renal failure, obstructive uropathy, diabetes mellitus, arthritis, non-Alzheimer's dementia, urinary retention, generalized edema, hydronephrosis, BPH, and urogenital implants. The resident's MDS also indicated the resident had an indwelling urinary catheter and no behaviors. During observations, the resident was lying in bed with the door open to the main hallway while the catheter drainage bag, about half full of yellow-amber urine, was hanging uncovered on the side of the bed and visible to other residents, visitors, and staff. Nursing staff stated the bag should be covered and that the resident needed assistance moving it from under the wheelchair to the side of the bed, and both RN and LPN staff confirmed it was uncovered and visible. The ADON and DON stated catheter bags should be covered at all times to maintain privacy and dignity, and the facility did not provide a policy related to catheter care and privacy.
Call light not kept within reach
Penalty
Summary
The facility failed to ensure a resident's call light was accessible. R74's records showed severe cognitive impairment, use of a wheelchair, dependence on staff for dressing, hygiene, bathing, and transfers, substantial assistance needed for bed mobility, and incontinence. The resident's care plan directed staff to keep the call light within reach and to provide prompt response to requests for assistance, and the facility's call light policy stated communication devices must be placed within reach of each resident. During observations, R74 was found in bed with the call light on the floor, under the roommate's bed, and not placed within reach. Staff were observed walking past the room, looking in the room, and continuing on without giving R74 the call light. During interview, NA-C stated R74 should always have the call light so staff can assist with needs, and LPN-B and LPN-C stated the call light should be in reach and that residents normally had clips to keep the light secure on the bed. The DON stated call lights should always be within reach and that clips should be closed in bed.
Failure to Notify Provider and Representative of Changes in Condition
Penalty
Summary
The facility failed to notify the resident, the resident’s guardian, and the provider about concerns involving severe toenail changes and refused podiatry appointments for a resident with severe cognitive impairment, intellectual disabilities, seizure disorder, and personality disorder. The resident required staff assistance with lower body dressing and had an order for weekly nurse skin checks. Podiatry notes documented that the resident refused scheduled treatment on two occasions, but the record lacked documentation that the guardian was informed of the refusals or that the provider was aware of the toenail condition. After discharge from the facility, the resident was taken to the emergency room, where the toenails were described as significantly thickened and discolored, with a diagnosis of fungal infection of the toenails and treatment started with terbinafine. The facility also failed to notify the provider of repeated diarrhea episodes for a resident with intact cognition and multiple chronic diagnoses including hemiplegia following cerebral infarction, hypertension, GERD, renal failure, diabetes, arthritis, stroke, anxiety disorder, and adjustment disorder. The record showed multiple episodes of diarrhea over an extended period, but there was no documentation that the provider was informed. Staff interviews confirmed the resident had frequent diarrhea for about a month, that scheduled Senna had been continued, and that the provider had not been made aware of the ongoing diarrhea. The ADON and DON both confirmed the diarrhea represented a change in condition and that provider notification should have occurred. The facility further failed to notify the provider of significant weight gains for another resident with intact cognition and diagnoses including heart failure, hypertension, hyperlipidemia, schizophrenia, pulmonary embolism, hypoxemia, thrombocytopenia, deep vein thrombosis, hypothyroidism, and dysthymic disorder. The resident had a physician order to notify the provider for weight gain greater than 2 pounds in 24 hours or 5 pounds in one week. Weight records showed multiple gains exceeding the ordered thresholds, including a 7.5-pound gain over one day, but the medical record lacked documentation that the provider was notified. Staff interviews confirmed weights were obtained and recorded, the notification parameters were present, and provider notification was not consistently completed.
Resident Information Left Visible on Unattended Medication Cart Computer
Penalty
Summary
The facility failed to maintain the confidentiality of resident personal and medical information for 1 of 1 resident observed, R98, by leaving resident-identifiable information visible on a laptop computer screen on a medication cart in a public hallway. During observation, the medication cart was unattended outside resident rooms, and the open screen faced outward toward the hallway, displaying R98’s full name, date of birth, medication list, and diagnoses. Multiple staff members, visitors, and residents passed through the area while no staff member was present to monitor or secure the computer screen. R98’s annual MDS identified the resident as cognitively intact and independent with ADLs. R98’s diagnoses included heart failure, hypertension, diabetes mellitus, renal failure, and anxiety disorder. During interview, RN-A confirmed the laptop was logged into the facility’s electronic medical record system and acknowledged the information displayed was confidential, stating staff were expected to log off or close the screen when stepping away from the medication cart. The DON later stated staff were educated on protecting resident privacy and confirmed that leaving resident information visible on an unattended computer screen in a public area was not consistent with facility expectations or resident privacy requirements.
Dirty Resident Room Floors
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for 2 residents, R55 and R108, by not keeping their room floors free of visible dirt and debris. R55’s quarterly MDS identified intact cognition and a need for assistance with ADLs, and diagnoses included heart failure, hypertension, hyperlipidemia, schizophrenia, pulmonary embolism without acute cor pulmonale, hypoxemia, thrombocytopenia, acute embolism and thrombosis of deep veins of the left upper extremity, hypothyroidism, and dysthymic disorder. During observations on 12/1/25, 12/2/25, and 12/3/25, R55’s room floor was repeatedly observed to be visibly soiled with accumulated dust, darkened residue adhered to the floor surface, debris beneath the bed and bedside table, and sticky areas near the bed and wheelchair path, with no evidence of recent cleaning. R108’s quarterly MDS identified moderate cognitive impairment and a need for assistance with ADLs, and diagnoses included stroke, hemiplegia following cerebral infarction affecting the right dominant side, anemia, hypertension, renal failure, wound infection, diabetes mellitus, hyperlipidemia, arthritis, aphasia, seizure disorder, anxiety disorder, depression, COPD, furuncle of the buttock, immunodeficiency, and mood disorder due to a known physiological condition. During observations on 12/1/25, 12/2/25, and 12/3/25, R108’s room floor was also repeatedly observed to be visibly soiled with accumulated dust, darkened residue adhered to the floor surface, and debris beneath the bed and bedside table, with no evidence of recent cleaning. The HSK-A stated resident room floors were expected to be cleaned daily and acknowledged the observed floors were not in a clean condition, and the DON stated resident rooms were expected to be maintained in a clean and sanitary condition at all times.
MDS Incorrectly Coded Anticoagulant Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect anticoagulation status for one resident whose admission MDS listed a history of stroke, coronary artery disease, and hypertension. The Resident Assessment Instrument 3.0 User’s Manual stated that antiplatelet medications such as clopidogrel should not be coded as an anticoagulant in N0415E, and the MDS section N instructions directed staff to code medications by pharmacological classification based on use during the lookback period. The resident’s MDS indicated both an anticoagulant and an antiplatelet were taken, but the physician order form did not show an anticoagulant order, and the October 2025 MAR and TAR showed clopidogrel bisulfate 75 mg daily starting 10/23/25 through 10/31/25 with no evidence of any anticoagulant medication being administered. During interview, the MDS nurse stated she used the MAR to determine whether a medication was administered during the lookback period and verified that the resident was on clopidogrel, which she identified as an antiplatelet, and stated she did not see where the resident received an anticoagulant. She stated she would have to modify the MDS and said it was important to code the MDS correctly because the resident did not receive anticoagulants. The DON stated she expected the MDS to be coded accurately, said they reviewed coding, and stated she forgot clopidogrel was an antiplatelet and that the MDS RN completed the coding based on the orders. A policy was requested, but the DON was not sure if the facility had one.
Care Plans Not Updated to Reflect Current Resident Needs
Penalty
Summary
The facility failed to ensure resident-centered care plans were developed, implemented, and revised to accurately reflect current resident needs for 3 of 3 residents reviewed. The report identified deficiencies in care planning related to edema management, discontinued enhanced barrier precautions, and conflicting instructions about eating assistance. A facility policy regarding the development, updating, and revision of resident care plans was requested but was not received. For R55, the quarterly MDS identified intact cognition and need for assistance with ADLs. R55 had diagnoses including heart failure, hypertension, hyperlipidemia, schizophrenia, pulmonary embolism, hypoxemia, thrombocytopenia, deep vein thrombosis of the left upper extremity, hypothyroidism, and dysthymic disorder. Record review showed bilateral lower extremity edema documented in nursing progress notes and physician documentation, and an order for ACE wraps to the lower extremities for edema management. The care plan did not include interventions addressing ACE wraps or edema management, and the ADON and DON confirmed the intervention should have been reflected in the care plan. For R102, the annual MDS identified severe cognitive impairment, need for assistance with ADLs, and substantial to maximal assistance with eating. R102’s diagnoses included anemia, hypertension, GERD, BPH, renal failure, depression, malnutrition, dehydration, hypovolemia, and dysphagia. Record review showed R102 had previously required enhanced barrier precautions, but documentation indicated the precautions had been discontinued while the current care plan still listed them as an active intervention. For R109, the quarterly MDS identified intact cognition and need for assistance with ADLs, with diagnoses including hemiplegia following cerebral infarction, hypertension, diabetes mellitus, hyperlipidemia, malnutrition, bipolar disorder, dysphagia following cerebral infarction, unspecified protein-calorie malnutrition, and constipation. The care plan contained conflicting information about eating assistance, with one section stating one-person assistance and another stating set-up only, while staff interviews gave differing descriptions of the resident’s eating needs. The ADON and DON acknowledged the care plan was not accurate or consistent with the resident’s current needs.
Failure to Provide Clean Clothing and ADL Assistance
Penalty
Summary
The facility failed to ensure activities of daily living related to hygiene and grooming were provided in accordance with resident needs for one resident, R88, by not ensuring the resident wore clean clothing throughout the survey period. R88’s quarterly MDS identified moderate cognitive impairment and a need for assistance with ADLs. The resident’s diagnoses included cancer, anemia, hypertension, renal failure, obstructive uropathy, diabetes mellitus, arthritis, non-Alzheimer’s dementia, urinary retention, generalized edema, hydronephrosis, benign prostatic hyperplasia, and urogenital implants. The MDS also indicated the resident had an indwelling urinary catheter and did not exhibit behaviors. During observations on 12/1/25, 12/2/25, 12/3/25, and 12/3/25 later that day, the resident was repeatedly seen wearing the same visibly soiled clothing, including a shirt with food stains and pants with darkened areas and debris. The stains remained present across the observations, indicating the clothing had not been changed during the survey period. NA-A stated the resident required staff assistance with dressing and acknowledged the resident should have been provided clean clothing daily, confirming the clothing had not been changed during the observed days. LPN-D and NA-F stated the resident dressed himself but staff needed to assist if clothing was dirty. The ADON stated visibly dirty clothing should be changed immediately, and the DON stated residents were expected to be dressed in clean clothing daily and that staff should have offered and attempted to assist with changing clothing at least twice daily.
Failure to Offer Activities to a Bedbound Resident
Penalty
Summary
Activities were not provided or offered in accordance with resident needs and preferences for one resident who remained in bed throughout the survey period. R109’s quarterly MDS identified intact cognition and a need for assistance with ADLs. The resident’s diagnoses included hemiplegia following cerebral infarction affecting the right dominant side, hypertension, diabetes mellitus, hyperlipidemia, malnutrition, bipolar disorder, dysphagia following cerebral infarction, unspecified protein-calorie malnutrition, and constipation. During multiple observations, R109 was found lying in bed with the room dark and curtains drawn, and no activity materials were present. No staff were observed offering or providing activities, and the resident was not transported to group activities or observed receiving individualized activities. The record review showed no documentation that activities were offered during the survey period, and the activity record did not reflect participation or refusal. NA-A stated staff did not routinely offer activities unless the resident requested them, AA-A stated residents should be offered activities daily and acknowledged one-to-one activities were not occurring due to low staffing, and the DON confirmed R109 remaining in bed without activities being offered was not consistent with facility expectations.
Failure to Provide Requested Audiology Services
Penalty
Summary
The facility failed to ensure audiology services were available for a resident who had repeatedly requested hearing services. The resident had Parkinson's disease, dementia, and depression, and multiple records showed moderate cognitive impairment. Her annual and quarterly MDS assessments indicated adequate hearing and no hearing aid use, yet her HealthDrive consent forms dated 1/31/24 and 4/18/25 both showed she wanted to be seen for audiology. Care conference forms listed dental and eye exams but did not document any audiology visits, and the resident's record lacked evidence that she was ever seen by audiology. Staff interviews confirmed the resident had ongoing hearing difficulty and no hearing aids were in use. The resident stated she did not wear hearing aids, a family member said the facility would not bring her to an ear doctor, and staff reported they had to speak closely or into her ear for her to hear. The SW and HUC stated HealthDrive had not had an audiologist available for at least 6 months, that residents would be sent out for appointments if needed, and that no outside audiology appointment had been set up for the resident. The DON stated the resident had been added to a list in October, HealthDrive had no audiologist, and the resident was not brought back up because she did not have an acute concern.
Failure to Administer or Properly Document UTI Prevention Treatment
Penalty
Summary
The facility failed to ensure prescribed treatment for UTI prevention was administered or documented as refused for one resident who was cognitively intact, dependent on staff for toileting, and frequently incontinent of bowel and bladder. The resident’s diagnoses included chronic kidney disease, diabetes mellitus, and UTI. Her care plan identified alteration in elimination with a goal to be free from signs and symptoms of UTI. The medication administration record showed Estradiol Vaginal Cream ordered for UTI prevention, but the record contained multiple entries marked as refused in October and November 2025, and another refusal on 12/3/25. During observation, the resident took other morning medications from RN-B, but the Estradiol was not offered at that time. The resident stated she had only been offered the Estradiol once that she could remember and had refused it then, but could not recall when that occurred. RN-B stated the resident always refused the Estradiol, admitted she had not offered it yet that morning, and confirmed she had signed the MAR as refused even though she had not offered the medication. RN-B stated refusals should not be documented before the medication is offered and that consistent refusals should be reported to the provider. The NP and DON stated they would expect to be notified when residents consistently refuse a medication, and the LPN stated staff should not document a refusal without actually offering the treatment.
Failure to Maintain Specific Colostomy Orders and Implement Ordered Supplies
Penalty
Summary
The facility failed to ensure specific, patient-centered colostomy orders were in place and implemented for a resident with a colostomy. The resident had intact cognition, used a wheelchair, was dependent on staff for toileting hygiene, showering or bathing, and lower body dressing, and had diagnoses including unspecified dementia, anxiety, depression, and malnutrition. The resident’s care plan identified a colostomy with a goal of avoiding complications and included interventions for skin barrier use, cleansing with warm water, and inspection of the stoma and peristomal skin, but it did not identify the specific colostomy supplies the resident required. The resident’s physician orders were inconsistent and lacked current detail about the exact pouch and barrier ring to use. The record showed prior orders for specific supplies, but the active orders did not identify what type of colostomy bag to use or whether barrier rings were needed. Standing orders also did not provide direction for excoriated skin caused by colostomy leakage. Nursing documentation showed the pouch was changed repeatedly in November and December, but several notes lacked detail about the condition of the skin around the stoma or whether the stoma site had been assessed. On 11/26/25, the resident reported pain around the colostomy, the skin was described as raw, and a ring was applied to cover the raw area and prevent stool from touching it. Later notes documented severe pain around the stoma, and on 12/1/25 the pouch was leaking, stool was resting on the skin, and the peristomal skin was excoriated with burning discomfort. During interview and observation, the resident stated the skin around the stoma was sore and raw and that staff had used the wrong bag. An LPN stated the resident did not have a CeraRing at the time of observation, that the resident’s skin was excoriated because stool had been exposed to it, and that the resident’s stoma was depressed, allowing stool to work its way under the supplies. The LPN also stated the provider had not been notified when the skin was excoriated on 11/26/25. The NP stated she had not been notified of the earlier excoriation, and the DON confirmed the orders lacked specific supply information and that staff should know the exact supplies because they were ordered for a reason. The record and interviews showed the resident had received specific pouches and barrier rings from the DME supplier, but those items were not clearly reflected in the resident’s active orders at the time of the deficiency.
Oxygen Therapy Provided Without Physician Order
Penalty
Summary
The facility failed to ensure respiratory care and services were provided in accordance with physician orders and professional standards of practice for one resident, R109. R109’s quarterly MDS identified intact cognition and a need for assistance with ADLs, and the resident’s diagnoses included hemiplegia following cerebral infarction affecting the right dominant side, hypertension, diabetes mellitus, hyperlipidemia, malnutrition, bipolar disorder, dysphagia following cerebral infarction, unspecified protein-calorie malnutrition, and constipation. During observations, R109 was seen receiving oxygen via nasal cannula on multiple occasions, including at 9:18 a.m., 2:09 p.m., and 7:11 a.m. Record review found no physician’s order for oxygen therapy, and the medical record lacked documentation authorizing oxygen use, including the liter flow rate, route, or parameters for use. Staff interviews confirmed the resident was receiving oxygen continuously, with one LPN stating it was set at 2 liters per minute, and both the ADON and DON acknowledged there was no active physician’s order for oxygen therapy in the record.
Inaccurate Documentation of Medication Refusal, Dialysis Assessment, and Toenail Care
Penalty
Summary
The facility failed to maintain accurately documented medical records for 3 residents. For one resident with cognitive intactness, dependence for toileting and transfers, frequent bowel and bladder incontinence, and diagnoses including diabetes, chronic kidney disease, and UTI, the MAR documented Estradiol Vaginal Cream refusals on days when the medication had not yet been offered. During observation, the RN administered other medications but did not offer the Estradiol, then later confirmed she had already signed the MAR as refused even though the resident had not been offered the medication at that time. The RN stated she should not have documented the refusal before offering it. For another resident with ESRD and dialysis, the TAR documented "Dialysis-Monitor fistula for Bruit and Thrill every shift" and showed the task completed 55 times over the month, even though the resident had an external chest port for dialysis and no fistula. Progress notes also documented bruit and thrill present after dialysis. The resident stated staff usually checked vital signs and looked at the external port, but did not palpate or listen for bruit/thrill, and the NP, MD, and RN all stated bruit and thrill assessment was appropriate for a fistula, not an external central catheter. The RN stated the order appeared to be entered automatically and staff were just signing it off. For a third resident with severe cognitive impairment, intellectual disabilities, seizure disorder, and personality disorder, weekly skin inspections documented toenail care as not needed or completed, including entries that toenails were trimmed. However, the resident later had an ER visit for a bad toenail infection, with thickened, discolored toenails and red non-blanching papules on both feet, and was started on Lamisil. The ADON reviewed photos and stated the toenails looked overgrown, yellow, and thick and could not have been done as documented. The DON stated the record should have accurately described the toenails in the weekly assessments or a progress note.
Failure to Maintain Central Line Care and EBP
Penalty
Summary
The facility failed to maintain infection prevention and control measures for a resident with a central line indwelling device. The resident had moderate cognitive impairment and required substantial to maximal assistance with most ADLs and transfers. Diagnoses included spastic hemiplegia affecting the right dominant side, osteomyelitis, and a history of traumatic brain injury. The resident’s care plan identified enhanced barrier precautions (EBP) related to the IV central line and directed staff to use appropriate PPE during high-contact care, but the care plan later showed EBP as resolved even though the central line remained in place. The treatment record showed weekly sterile dressing changes for the right chest central line and EBP tasks in October and early November, but the November record lacked evidence that the dressing was changed and lacked evidence that the PICC line was removed as ordered. During observation, the dressing was not dated and the edges were curling up and peeling off. Staff observed providing hands-on care while wearing gloves only and no gown, despite the central line still being present. Interviews with the resident, NA, LPN, MD, and DON confirmed confusion about whether the line was still in use, that the line had not been pulled as ordered, and that EBP and central line care should have continued until the device was actually removed.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment posed risks that were not properly addressed, and supervision measures were insufficient to prevent potential incidents. No further details about the specific hazards, the nature of the supervision, or the residents involved are provided in the report.
Infection Control and EBP Failures in LTC Facility
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) and proper use of Personal Protective Equipment (PPE) during high-contact resident care activities. For instance, a resident with a central line did not have EBP signage or PPE available, and staff did not wear gowns during IV antibiotic administration. Another resident with a foley catheter and a history of antibiotic-resistant infections had a wound doctor who did not don a gown during wound care, despite EBP signage being present. Additionally, the facility did not ensure appropriate hand hygiene practices. A trained medication assistant changed gloves without performing hand hygiene after washing a resident's rectal area. Shared equipment, such as a Hoyer lift, was not disinfected between uses, as observed when a lift was moved from a resident's room to a spa room without being cleaned immediately. The facility also failed to store reusable ice packs separately from food in kitchen refrigerators, which is against infection control protocols. Ice packs were found touching residents' labeled food items in multiple kitchenettes, despite signage indicating the refrigerators were for resident food only. Staff interviews confirmed that ice packs should be stored in a separate medication freezer to prevent contamination.
Uncleaned Shower Room Vent in LTC Facility
Penalty
Summary
The facility failed to ensure that the ceiling exhaust fan in a multi-resident shower room on the third floor was cleaned, potentially affecting all residents using the shower room. Observations revealed that the vent was coated with gray debris, with some particles hanging off, indicating a lack of regular cleaning. Interviews with a resident, who had previously worked as a janitor, confirmed that the vent in the common shower room was in worse condition than the one in his room, which also contained dark debris. Interviews with staff, including a social worker, maintenance personnel, and housekeeping staff, highlighted a lack of clarity and responsibility regarding the cleaning of the vents. Maintenance staff indicated that vents were supposed to be cleaned monthly, while housekeeping staff claimed daily cleaning routines included dusting and cleaning vents. However, the presence of significant debris on the vent suggested these procedures were not followed. The facility was unable to provide a policy or checklist for daily cleaning, further indicating a gap in the implementation of cleaning protocols.
Failure to Respect Resident's Healthcare Decision Rights
Penalty
Summary
The facility failed to ensure a resident's right to determine their own healthcare decisions and to revoke a power of attorney. The resident, identified as R30, had intact cognition according to multiple assessments, yet the facility continued to involve a family member, FM-A, as the power of attorney for healthcare decisions without R30's consent. Despite R30's clear cognitive status and expressed desire to change the power of attorney, the facility did not facilitate this change or include R30 in care conferences. R30's medical records indicated a history of fluctuating cognitive status due to various medical conditions, including dementia, anxiety, depression, and acute illnesses like encephalopathy and diverticulitis. However, during periods of intact cognition, R30 expressed dissatisfaction with FM-A's involvement in healthcare decisions and sought to revoke FM-A's power of attorney. The facility's records lacked evidence of R30's participation in care planning or any re-evaluation of R30's decision-making capacity following acute illnesses. Interviews with R30 and facility staff revealed that R30 was not informed or invited to care conferences, and the facility continued to rely on FM-A for consent and decision-making. The social worker and director of nursing acknowledged that R30 should have been included in care conferences and decision-making processes, given her intact cognition. The facility's failure to recognize and act upon R30's expressed wishes and cognitive status led to a deficiency in respecting the resident's rights.
Failure to Notify Physician of Resident's Vision Loss
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident experiencing new vision loss. The resident, who had intact cognition and diagnoses of type II diabetes mellitus, hypertension, and congestive heart failure, was noted to have adequate vision and did not wear corrective lenses according to their care plan. However, the resident reported experiencing vision loss and irritation in the right eye, which had been occurring for three weeks. Despite this, there was no documentation that the physician had been notified or that an appointment had been made until much later. The resident had a visit summary note from an eye exam indicating the need for an urgent appointment with a retinal specialist, but the appointment was scheduled weeks later. The assistant director of nursing (ADON) and other nursing staff failed to assess the resident's eye condition or document the incident properly. The ADON admitted to not documenting the incident or notifying the provider, and the licensed practical nurse (LPN) only applied more tape to the bandage without assessing the eye. The Health Information Manager (HIM) was unaware of the urgency of the follow-up appointment and scheduled it for a later date, missing the 'ASAP' instruction from the eye doctor. Interviews with various staff members revealed a lack of communication and documentation regarding the resident's condition. The director of nursing (DON) stated that nurses were responsible for assessing new injuries or changes in condition, but this protocol was not followed. The facility's policy on notification of a change in condition was not adhered to, resulting in a delay in addressing the resident's vision issues. The resident expressed frustration over the lack of action taken by the facility, highlighting a significant deficiency in the care provided.
Failure to Include Swallow Study in Discharge Plan
Penalty
Summary
The facility failed to ensure that a swallow study referral was included in the post-discharge plan for a resident with dysphagia, among other medical conditions. The resident, identified as having intact cognition and several diagnoses including type one diabetes mellitus, dysphagia, and end-stage renal disease, was on a therapeutic diet and had active discharge planning in place. Despite the speech language pathologist's (SLP) recommendation for a swallow study due to esophageal dysphagia, the care plan did not include an intervention for the resident to make her own post-discharge appointments for the study. The SLP had evaluated and treated the resident, recommending a swallow study on 9/19/24, but the facility's records lacked documentation of whether the study was scheduled or discussed with the resident. The discharge instructions and summary form did not include arrangements for the swallow study, and the resident reported not being made aware of any such arrangements before discharge. Interviews with facility staff revealed a lack of communication and coordination regarding the scheduling of the swallow study, with various staff members assuming others were responsible for the task. The facility's discharge planning policy required coordination by the interdisciplinary team to ensure continuity of care, but this was not effectively executed in this case. The resident expressed a desire for the facility to assist in scheduling the swallow study, as she was unsure how to do it herself. The failure to include the swallow study referral in the discharge plan highlights a breakdown in communication and responsibility among the facility's staff, leading to a deficiency in meeting the resident's post-discharge needs.
Failure to Provide Timely Vision Care
Penalty
Summary
The facility failed to ensure that a resident received proper treatment to maintain vision, as evidenced by the case of a resident with intact cognition and diagnoses of type II diabetes mellitus, hypertension, and congestive heart failure. The resident's care plan indicated adequate vision and no need for corrective lenses, with an intervention to observe for changes in visual status. However, the resident's last eye exam recommended an urgent appointment with a retinal specialist, which was not promptly scheduled. The resident experienced vision loss and reported symptoms such as looking through a red fog, which had been occurring for three weeks without appropriate intervention from the facility. The assistant director of nursing (ADON) acknowledged that the resident returned from dialysis with a patch over his eye and new orders but did not consider it a cause for concern. The ADON failed to document the incident or notify the provider, and no assessment of the resident's eye was conducted by the nursing staff. Interviews with various nursing staff revealed a lack of documentation and assessment of the resident's eye condition, despite the presence of a new bandage and the resident's complaints of irritation and vision issues. The Health Information Manager (HIM) was unaware of the need for an urgent follow-up appointment and only learned of the resident's eye issues when the resident personally reported them. The HIM admitted to missing the urgency indicated in the visit summary and scheduled the specialist appointment weeks later. The facility's policy on ancillary appointments was requested but not provided, indicating a possible lack of protocol in managing such situations. The director of nursing (DON) outlined the expected procedure for handling changes in condition, which was not followed in this case.
Failure to Provide Updated Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that two residents, identified as R5 and R20, were offered and/or provided updated vaccinations for pneumococcal disease in accordance with CDC recommendations. R5, who was at increased risk due to chronic obstructive pulmonary disease, heart failure, and a history of acute respiratory failure, had received PCV-13 and PPSV23 vaccines in 2015. Although R5 consented to receive additional pneumococcal vaccines per CDC guidelines, her medical record lacked documentation of shared clinical decision-making regarding further vaccination. The Director of Nursing (DON) stated that shared clinical decision-making was not completed because R5's vaccines were considered complete according to the Minnesota Immunization Information Connection (MIIC), and the DON had not reviewed the vaccines in accordance with updated CDC recommendations. R20, who was also at increased risk due to conditions such as pulmonary embolism, dyspnea, chronic heart failure, and obstructive sleep apnea, had a vaccine consent form indicating previous receipt of PPSV23 and PCV-13, but the dates were unclear. Her immunization form showed no history of pneumococcal vaccinations, and her medical record lacked follow-up regarding the declination or administration of the vaccines. The DON acknowledged that no one had followed up to verify R20's vaccine history. The facility's policy required offering vaccines within 30 days of admission unless already vaccinated or contraindicated, and to verify immunization status if unknown, but these steps were not adequately followed for R20.
Resident Excluded from Care Conferences Despite Intact Cognition
Penalty
Summary
The facility failed to ensure that a resident, identified as R30, was invited to participate in care conferences, which is a requirement for care planning. R30, who had intact cognition and was capable of making her own decisions, was not included in care conferences, and there was no documentation indicating that she refused to attend or that her participation was not practicable. Despite having a health care directive that appointed a family member as her health care agent, R30 expressed dissatisfaction with not being included in healthcare decisions and care conferences. R30's medical records and interviews revealed that she was alert and oriented, with adequate long-term recall and fair short-term recall. She had a history of anemia, hypertension, dementia, anxiety, depression, and borderline personality disorder. Despite these conditions, R30 was capable of participating in her care planning, as evidenced by her ability to express her preferences and dissatisfaction with the current arrangement where her family member was contacted instead of her. Interviews with facility staff, including the social worker and director of nursing, indicated a lack of clarity and communication regarding R30's participation in care conferences. The social worker acknowledged that R30 should have been asked if she wanted to attend care conferences, given her intact cognition. The facility's policy stated that residents have the right to participate in their healthcare planning, but this was not adhered to in R30's case, leading to the deficiency.
Inadequate Smoking and Behavioral Assessments Lead to Safety Hazards
Penalty
Summary
The facility failed to adequately assess and supervise a resident, R15, for safe smoking practices. R15, who was cognitively intact and used intermittent oxygen therapy, had a history of smoking incidents, including lighting a cigarette in her room and dropping ash on her clothing. Despite these incidents, the facility did not conduct timely smoking assessments as required by their policy. R15's care plan indicated she was initially assessed as safe to smoke independently, but subsequent assessments revealed safety concerns, such as burn holes in her clothing and the need for a smoking apron. The facility's failure to conduct quarterly assessments and address these safety hazards contributed to the deficiency. Additionally, the facility did not adequately address a safety hazard involving resident-to-resident abuse. R50, who had moderate cognitive impairment and a history of depression and substance use, was involved in an altercation with another resident, R71, who was intoxicated and made inappropriate comments. R50, feeling threatened, used his wheelchair to confront R71, leading to a physical altercation. The facility's care plan for R50 included interventions to manage his behavior and ensure his safety, but these measures were not effectively implemented, as evidenced by the altercation and R50's continued agitation and use of a flashlight for self-defense. The facility's policies and procedures for smoking assessments and managing resident behavior were not consistently followed, leading to safety hazards for both R15 and R50. The lack of timely assessments and interventions for R15's smoking safety and R50's behavioral issues contributed to the deficiencies identified in the report. The facility's failure to act upon identified safety hazards and ensure adequate supervision and assessment of residents' needs resulted in potential risks to resident safety.
Deficiency in Oxygen Tubing Maintenance and Documentation
Penalty
Summary
The facility failed to ensure that supplemental oxygen was properly maintained and accurately documented for a resident with intact cognition and diagnoses including pulmonary embolism and unspecified dyspnea. The resident had physician orders to monitor for skin breakdown due to oxygen tubing, follow enteric contact precautions due to C. Difficile, and maintain oxygen saturations at 88% or above with 2 liters of oxygen. The resident's medication administration record (MAR) and treatment administration record (TAR) indicated that oxygen tubing was to be changed weekly, but observations revealed that the tubing had not been changed as required, with a sticker on the tubing dated 9/3, despite documentation indicating otherwise. Interviews with staff, including a registered nurse (RN) and the assistant director of nursing (ADON), confirmed that the oxygen tubing was not changed weekly as per the orders, and the documentation in the TAR was inaccurate. The assistant director of nursing acknowledged that the staff should not have signed off on the task if it was not completed, highlighting the importance of changing the tubing for infection control. The director of nursing (DON) confirmed the lack of a specific policy on oxygen tubing but expected staff to follow batch orders and document accurately. The deficiency was identified through observations and staff interviews, revealing a lapse in following professional standards for respiratory care and documentation accuracy.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident to the State Agency (SA) within the required timeframe. The resident, who had moderate cognitive impairment and was dependent on staff for all hygiene care, mobility, and transfers, reported being raped at the facility to a family member over the phone. This report was overheard by a nursing assistant (NA) and a licensed practical nurse (LPN) who were present in the room. Despite hearing the allegation, the LPN did not report it immediately, as required by facility policy and state regulations. The incident occurred on the evening of 9/14/24, but the facility did not report it to the SA until the morning of 9/16/24, well beyond the two-hour reporting requirement. The NA assumed the LPN would report the incident, while the LPN, despite acknowledging hearing the allegation, did not take action to report it, citing being preoccupied with other duties. The Director of Nursing (DON) confirmed that both the NA and LPN were aware of the allegation on the day it occurred but failed to report it as mandated. The facility's policy clearly states that any suspected abuse must be reported immediately, not later than two hours after the suspicion arises. The administrator confirmed that the expectation and policy were not followed, as the report to the SA was delayed. This failure to report in a timely manner constitutes a deficiency in the facility's adherence to abuse reporting protocols.
Failure to Monitor Edema and Assess Non-Pressure Related Wounds
Penalty
Summary
The facility failed to monitor edema and comprehensively assess non-pressure related wounds for a resident with multiple health conditions, including brain cancer, hypertension, and chronic ischemic heart disease, who was receiving hospice care. The resident's physician orders required nurses to chart the resident's condition every shift for edema and lung checks, but the documentation was inconsistent and lacked comprehensive details. The treatment administration records indicated the presence or absence of edema and lung sounds but did not include the extent of the edema. Additionally, the resident's weight gain of 16.2 pounds over a period was not comprehensively assessed to determine if it was nutritional or fluid-related, and there was no evidence that the weight gains were evaluated for changes in the resident's overall health status and possible disease progression. The resident's skin evaluations and wound assessments were also found to be lacking. Multiple skin inspections and wound evaluations noted various bruises, skin tears, and wounds, but the documentation often did not include specific details such as wound measurements, wound beds, drainage, odor, periwound area, wound edges, risk factors, and pain. The resident's care plan identified a risk for alteration in skin integrity but did not include interventions related to edema. The facility's policies on skin assessment and wound management were not fully adhered to, as comprehensive assessments and follow-up interventions were not consistently documented. Interviews with the facility's staff, including the Director of Nursing (DON), revealed that edema was not being specifically monitored every shift as required by the physician's order. The DON acknowledged that the documentation of edema and weight monitoring was inadequate and that the resident's care plan did not include edema management. The facility's policies on resident weight evaluation and skin assessment were not fully implemented, leading to deficiencies in the monitoring and assessment of the resident's condition.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,005 citations issued within 25 miles in the last 12 months — including the 32 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Maplewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harmony Gardens | 1.1 mi | ★★★★★ | 7 | 0 |
| Good Samaritan Society - Maplewood | 2.9 mi | ★★★★★ | 16 | 0 |
| Cerenity Marian Of St Paul Llc | 4.7 mi | ★★★★★ | 5 | 0 |
| Cerenity Care Center White Bear Lake | 4.9 mi | ★★★★★ | 8 | 1 |
| Capitol View Transitional Care Center | 5.3 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.