Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Health Care Center during CMS and state inspections, most recent first.
Failure to Use PPE During Isolation Care and Medication Administration: Staff did not use required PPE during resident care and medication-related tasks. A CNA entered a resident’s room on droplet/contact precautions and handled a meal tray without PPE, an LPN performed PICC-related care and repositioning in the same room without appropriate PPE, an LPN administered G-tube medications in an EBP room without a gown, and another LPN gave a subcutaneous injection without gloves. The residents involved had diagnoses including ESBL UTI, influenza, chronic kidney disease, diabetes, dysphagia, and other chronic conditions.
A staffing deficiency in an LTC facility led to Immediate Jeopardy when a resident experienced a change in condition without a nurse available for assessment, resulting in a 911 call and hospital admission. Another resident missed a morning blood glucose check and medications, leading to a dangerously high blood glucose level. The deficiency was due to a nurse not reporting to work, leaving one LPN to cover two halls, and a delay in contacting the on-call nurse.
The facility failed to prevent and adequately treat pressure ulcers for two residents. One resident developed a preventable pressure ulcer on her hand due to long fingernails, while another resident with a Stage 4 sacral ulcer missed multiple treatments. The facility's records showed inconsistencies in documenting skin assessments and treatments, and the Interim DON confirmed that treatments should not be missed.
A resident with multiple diagnoses and high fall risk fell twice due to the facility's failure to implement required two-person assistance for bed mobility. The CNA involved was unaware of the care plan, leading to the resident sustaining a fractured hip. The facility's oversight resulted in actual harm to the resident.
The facility failed to maintain sanitary conditions in its kitchen, with observations of dirty floors, equipment, and carts. Additionally, the facility did not adhere to its policies for monitoring and documenting food and equipment temperatures, with numerous missing logs. Staff interviews confirmed these deficiencies, acknowledging the unclean state and lack of documentation.
The facility did not provide a private space for a Resident Council meeting, as required by policy. During the meeting, the Maintenance Director and Assistant entered the room, disrupting the residents. Interviews with the Activity Director and DON confirmed the need for privacy, highlighting a failure to adhere to policy and residents' rights.
The facility did not provide a private space for a Resident Council meeting, as required by policy. During the meeting, the Maintenance Director and Assistant entered the room, disrupting the session. Interviews with the Activity Director and DON confirmed the need for privacy during such meetings.
A resident with severe cognitive impairment was transferred to a hospital without the facility notifying the resident's legal representative, as required by policy. The facility's progress note inaccurately stated that the responsible party was aware, but the notification only occurred after the hospital informed the resident's daughter, who then contacted the facility. The Interim DON acknowledged that notification should occur within an hour of transfer.
The facility failed to maintain a sanitary environment in several resident rooms, with observations of unclean conditions such as dirty baseboards, splatter marks on blinds, and sticky floors with odors. Interviews confirmed that the facility's cleaning standards were not met, as rooms and bathrooms should be clean and odor-free.
The facility failed to report allegations of abuse and an injury of unknown origin involving three residents. A resident reported verbal abuse by a staff member, which was not reported to the state agency for nine days. Another resident, who was severely cognitively impaired, had a bruise on her forehead that was not documented or investigated. A third resident reported a physical altercation with a nurse, which was initially treated as a complaint rather than abuse. The facility acknowledged the need for documentation and investigation in these cases.
The facility failed to investigate alleged abuse incidents involving two residents. One resident, who was severely cognitively impaired, had a bruise on the forehead that was not documented or investigated. Another resident, who was cognitively intact, reported an incident involving a nurse that was not classified as abuse by the facility. The lack of thorough investigation and documentation indicates a deficiency in handling abuse allegations.
A facility failed to develop a comprehensive care plan for a resident at risk for pressure injuries. Despite the facility's policy requiring documentation and communication of interventions, the care plan lacked necessary interventions for wound care to the resident's hand. The MDS Coordinator confirmed the absence of required interventions, highlighting a failure to adhere to policy and address the resident's care needs.
The facility did not conduct a quarterly care plan conference with a resident or their family representative, as required by policy. The resident, who has multiple health issues and is dependent on staff, did not have a documented care plan meeting following their quarterly MDS assessment. Interviews confirmed the omission of the family representative in the care planning process.
A facility failed to maintain accurate records and reconcile controlled medications for a nurse observed during medication administration. Discrepancies were found in the narcotic reconciliation records for three residents, with differences between the controlled drug records and the actual counts of medications like Gabapentin, Alprazolam, and Hydrocodone/Acetaminophen. The LPN admitted to administering doses without updating the narcotic book, and the Interim DON confirmed that narcotics should be signed out immediately after administration.
The facility failed to properly store and label medications, as expired Humalog pens were found in the medication room, and an over-the-counter medication was improperly stored in a shared bathroom. The Assistant Director of Nursing and Interim DON confirmed these storage practices were incorrect.
An LPN failed to follow proper infection control procedures during ostomy care for a resident with multiple diagnoses, including Dementia and Quadriplegia. The LPN did not change gloves or wash hands after cleaning the stoma and before applying a new ostomy bag, contrary to the facility's hand hygiene policy. This was confirmed by the LPN and nursing leadership.
Failure to Use PPE During Isolation Care and Medication Administration
Penalty
Summary
The facility failed to maintain and ensure the prevention and spread of infection when staff did not use PPE during care and medication-related activities for residents on Transmission-Based Precautions and Enhanced Barrier Precautions. The facility policies reviewed stated that staff should don appropriate PPE before or upon entry into a resident’s environment on transmission-based precautions, and that gowns and gloves are required for contact precautions and targeted high-contact care activities under enhanced barrier precautions. Resident #7 was admitted with diagnoses including UTI with ESBL resistance and influenza, and had physician orders for Contact Isolation related to ESBL in urine and Droplet Precautions related to flu. During observation, a CNA entered the resident’s room carrying a dining tray, placed the tray on the over-bed table, and assisted with the meal without donning PPE. Later, an LPN entered the same room, removed tubing from the resident’s PICC line, and turned and repositioned the resident without wearing the appropriate PPE. The ICP stated staff should dress out with all PPE, including gown, gloves, and mask, and should do so when delivering trays or having close contact with a resident in isolation. Resident #47 had diagnoses including chronic kidney disease, dysphagia, diabetes, and a gastrostomy tube, and was severely cognitively impaired. During medication administration through the G-tube, an LPN prepared crushed medications and liquids, entered the resident’s room without donning PPE, performed hand hygiene, donned gloves, checked tube placement and residual, and administered the medications through the G-tube. The LPN did not wear a gown in the EBP room. Resident #114 had diagnoses including diabetes, atrial fibrillation, anemia, and kidney disease, and was moderately cognitively impaired. During medication administration, an LPN entered the resident’s room and gave a subcutaneous Repatha injection without donning gloves. The DON stated gloves should be worn when administering an injection.
Staffing Deficiency Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to provide sufficient licensed nursing staff to perform necessary assessments and administer morning medications as ordered for six residents. This deficiency resulted in Immediate Jeopardy when a resident experienced a change in condition, and no nurse was available to assess the resident. The resident's spouse had to call 911, leading to the resident being evaluated in the Emergency Department and admitted to the hospital. Another resident did not receive a morning blood glucose check, scheduled insulin, or Metformin, resulting in a dangerously high blood glucose level later in the day. The facility's staffing issues were evident on a specific day when a scheduled nurse did not report to work, leaving one LPN to cover two halls with a total of 49 residents. This LPN was unable to provide care for the residents on one hall due to the workload on the other hall, which included a hospice resident requiring significant attention. The on-call nurse was not contacted until several hours into the shift, and by the time they arrived, the residents had already missed their scheduled medications and assessments. Interviews with staff and documentation reviews revealed a breakdown in communication and staffing procedures. The DON was informed early in the shift about the absence of the scheduled nurse but did not ensure that the on-call nurse was contacted promptly. The staffing coordinator was not notified until midday, and the on-call nurse did not arrive until nearly seven hours after the shift began. This delay in staffing coverage led to significant lapses in resident care, including missed medication administrations and assessments.
Removal Plan
- Education was provided to the RDCS, Administrator, and Director of Nursing by the VP of Clinical Services and the Chief Operating Officer regarding On-Call Procedures.
- The off going nurse will remain at the facility to complete medication administration and to ensure resident care is continued until the Nurse Manager on call or oncoming nurse has arrived to relieve the off going charge nurse.
- Procedure of notifying the physician following assessing all potentially affected residents for further direction of action related to delayed or missed medication administration.
- Ongoing monitoring plan to prevent recurrence.
- All hall residents were evaluated for delayed medications by the Director of Nursing and Licensed Practical Nurse.
- All applicable Residents' blood glucose levels were assessed per accucheck with physician notification completed.
- The Medical Director was notified by the DON for notification of all delayed medications and missed accuchecks and insulin administration with current blood glucose levels obtained.
- The Medical Director was included in adhoc Quality Assurance and Performance Improvement (QAPI) meeting.
- All on duty Licensed Nurses were educated by the Director of Nursing and Regional Director of Clinical Services regarding On-call procedures, communication, timely medication administration, reinstructed regarding abuse prohibition and neglect, and staffing procedures.
- The Director of Nursing and Regional Director of Clinical Services completed a Medication Administration audit for all residents.
- A Governing Body meeting was held with the Administrator, Director of Nursing, Regional Director of Clinical Services, and VP of Clinical Services to discuss the notification of immediate jeopardy.
- Adhoc QAPI meeting held with the Medical Director to share Removal and in agreement with Plan of Correction and Monitoring in place.
- The Director of Nursing and/or Assistant Director of Nursing will audit medication administration competition.
- Monitoring will occur twice daily, then twice daily during business days, then weekly thereafter during morning clinical meeting.
- The Director of Nursing will report the findings to the monthly QAPI Committee meeting.
- Removal plan was discussed and approved by Medical Director.
- The Administrator will ensure the removal plan is completed.
Failure in Pressure Ulcer Prevention and Treatment
Penalty
Summary
The facility failed to provide adequate care and services to prevent the development of pressure ulcers and to treat existing ones for two residents. One resident, who was at risk due to contractures and required assistance with activities of daily living, developed a pressure ulcer on the palm of her left hand due to long fingernails digging into the skin. Despite being cognitively intact, the resident was dependent on staff for personal care, including nail trimming, which was not adequately performed. The facility's records showed inconsistencies in documenting skin assessments and treatments, and the wound was not identified in a timely manner. Another resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, had a Stage 4 pressure ulcer on the sacral area. The facility's treatment administration records revealed multiple instances where prescribed treatments for the pressure ulcer were missed. The Interim Director of Nursing confirmed that treatments should not be missed and that any missed treatments should be documented with a reason. Interviews with the treatment nurse and the Director of Nursing confirmed that the pressure ulcer on the first resident's hand was preventable and should have been identified during routine skin assessments. The facility's failure to adhere to its policies on pressure injury prevention and management, as well as the lack of documentation and follow-through on prescribed treatments, contributed to the deficiencies identified in the care of these residents.
Failure to Implement Fall Interventions Results in Resident Injury
Penalty
Summary
The facility failed to implement fall interventions for a resident, resulting in actual harm. The resident, who was admitted with multiple diagnoses including left hemiplegia, Parkinson's, and dementia, was assessed as high risk for falls. Despite this, the facility did not adhere to the care plan that required two-person assistance for bed mobility. On two separate occasions, the resident fell from the bed, sustaining injuries including a fractured hip. On the first incident, the resident was found on the floor with multiple injuries, and it was noted that two staff members were required for assistance. However, during the second incident, a CNA was providing care alone when the resident fell again, leading to a hip fracture. The CNA involved was unaware of the two-person assistance requirement, as they had just started working on that side of the facility. Interviews with staff revealed that the CNA was not informed of the resident's care plan requirements, and the RN on duty was not present during the fall. The resident, who was cognitively intact, expressed pain and was eventually transferred to the hospital for evaluation and treatment. The facility's failure to follow the established care plan and ensure adequate supervision directly contributed to the resident's injury.
Sanitation and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, as evidenced by multiple observations of unclean equipment and surfaces. The kitchen floor was consistently found to be dirty with dried food crumbs and debris, and the convection oven had a significant buildup of dried food particles and a thick black sticky substance. Additionally, various carts used for meal service and storage were observed to be dirty and contained food particles. The facility also failed to adhere to its own policies regarding the monitoring and documentation of food and equipment temperatures. Logs for food temperatures, freezer temperatures, cooler temperatures, and dish machine sanitation were incomplete or missing for numerous days across several months. This lack of documentation indicates a failure to ensure that food was stored, prepared, and served at safe temperatures, and that dishwashing equipment was operating under sanitary conditions. Interviews with facility staff, including the Registered Dietician and Certified Dietary Manager, confirmed these deficiencies. The staff acknowledged the unclean state of the kitchen and the failure to document required temperature checks. The Certified Dietary Manager admitted to not enforcing the necessary standards and expressed awareness of the facility's shortcomings in maintaining compliance with state regulations.
Failure to Provide Privacy for Resident Council Meeting
Penalty
Summary
The facility failed to provide a private space for the Resident Council meeting, as required by their policy titled 'Resident Council Procedural Guide' dated 11/28/2017. During the meeting held in the Dining Room, the Maintenance Director and Maintenance Assistant entered the room and walked in front of the residents, disrupting the meeting. Interviews with the Activity Director and the Director of Nursing confirmed that a private place should be provided for uninterrupted resident council meetings, indicating a failure to adhere to the facility's policy and the residents' rights to privacy during their meetings.
Failure to Provide Private Space for Resident Council Meeting
Penalty
Summary
The facility failed to provide a private space for the Resident Council meeting, as required by their policy. The policy, dated 11/28/2017, states that residents have the right to organize and participate in resident groups and must be provided with privacy for meetings. During a Resident Council meeting in the Dining Room, the Maintenance Director and Maintenance Assistant entered the room and walked in front of the residents, disrupting the meeting. Interviews with the Activity Director and the Director of Nursing confirmed that a private place should be provided for uninterrupted resident council meetings.
Failure to Notify Resident's Representative of Hospital Transfer
Penalty
Summary
The facility failed to notify the legal representative of a resident about the resident's transfer to a hospital, which is a requirement according to the facility's policy. The policy mandates that the resident's family member or legal representative must be informed of any significant changes, including transfers or discharges. In this case, the resident, who had severe cognitive impairment due to conditions such as Dysphagia, Dementia, Alzheimer's Disease, and Gastro-Esophageal Reflux, was transferred to a hospital following episodes of vomiting. The facility's progress note indicated that the responsible party was aware of the transfer, but this notification occurred only after the hospital had already informed the resident's daughter, who then contacted the facility for confirmation. Interviews conducted during the investigation revealed that the resident's responsible party was not notified by the facility at the time of the transfer. The Interim Director of Nursing stated that the responsible party should be notified within an hour of the transfer, acknowledging that immediate notification might not occur in emergencies but should happen as soon as the resident is out of the building. This failure to promptly notify the responsible party of the resident's transfer constitutes a deficiency in the facility's adherence to its notification policy.
Facility Fails to Maintain Sanitary Environment in Resident Rooms
Penalty
Summary
The facility failed to maintain a sanitary environment in several resident rooms, as evidenced by multiple observations of unclean conditions. In Resident #3's room, dirty baseboards and window blinds with yellowish-brown splatter marks were noted. The commode had a grayish-black ring and a dark brown smear above the water line. In the shared bathroom of Residents #82 and #94, a strong odor of urine was present, and the floor was sticky with visible footprints and wheelchair marks. Dirt, crumbs, and dark streaks were observed on the floor and walls. In the room shared by Residents #34 and #61, the window valance had a thick gray dusty buildup. In the room of Residents #28 and #84, the base of the enteral feeding tube pole had a yellowish tan hardened substance, and crumbs and dirt were present on the floor. Interviews with the Administrator and the Head of Housekeeping confirmed that the facility's cleaning standards were not met, as resident rooms and bathrooms should be clean, odor-free, and without visible dust or dirt.
Failure to Report Allegations of Abuse and Injury
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving Resident #76, who was cognitively intact with a BIMS score of 15. The resident reported to a surveyor that a staff member called him a derogatory name. Although the surveyor informed the Administrator of the allegation, it was not reported to the state agency until nine days later. The Administrator acknowledged the failure to report the incident promptly. Resident #81, who was severely cognitively impaired with a BIMS score of 00, was found with a bruise on her forehead, which was not documented or investigated by the facility staff. The bruise was first noted in a progress note, but subsequent skin checks did not report it. The resident's daughter discovered the bruise when the resident was hospitalized, and the facility later acknowledged the need for documentation and investigation of the injury. Resident #307, who was cognitively intact, reported an incident where a nurse allegedly tried to take his phone, leading to a physical altercation. The resident claimed the nurse put a towel over his face, which he perceived as smothering. The incident was initially reported as a complaint rather than abuse, and the Administrator did not report it to the state agency until later. The Administrator and Social Service Director did not perceive the incident as abuse, despite the resident's account.
Failure to Investigate Alleged Abuse Incidents
Penalty
Summary
The facility failed to thoroughly investigate alleged abuse incidents involving two residents. For Resident #81, who was severely cognitively impaired, a bruise was noted on the forehead, but no incident report or investigation was conducted. The bruise was first observed on 12/25/2024, but it was not documented or reported as required by the facility's policy. The resident's daughter was not informed of the incident by the facility, and the bruise was only noted when the resident was hospitalized. Interviews with staff revealed a lack of clarity on the origin of the bruise, and the Interim DON confirmed that the incident should have been documented and investigated immediately. For Resident #307, who was cognitively intact, an incident occurred where the resident called 911, alleging that a nurse attempted to take his phone and subsequently restrained him with a towel over his face. The resident reported feeling unsafe and wanted to press charges. However, the facility's administration did not classify the incident as abuse, instead treating it as a complaint. The Administrator and Social Service Director did not perceive the incident as abuse, and the facility did not conduct a thorough investigation or report it as required. The facility's failure to investigate these incidents thoroughly and document them as per policy indicates a deficiency in handling allegations of abuse. The lack of immediate and appropriate response to these incidents, including failure to notify family members and conduct proper investigations, highlights a significant oversight in the facility's adherence to its policies on abuse, neglect, and incident reporting.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident identified as being at risk for pressure injuries. The facility's policy on Pressure Ulcer Prevention and Management mandates that nursing assistants inspect the skin during baths and report any concerns to the resident's nurse in a timely manner, with interventions documented in the care plan and communicated to all relevant staff. However, the care plan for the resident, who was admitted with diagnoses including Hemiplegia, Epilepsy, and knee contractures, lacked necessary interventions for wound care to the palm of the left hand, despite the resident being cognitively intact and requiring substantial assistance with activities of daily living (ADLs). The deficiency was confirmed during an interview with the Minimum Data Set (MDS) Coordinator, who acknowledged that there should have been an intervention on the care plan for the trauma from nails to the palm of the left hand. The absence of a documented intervention in the care plan indicates a failure to adhere to the facility's policy and to address the resident's specific care needs, particularly concerning the prevention and management of pressure injuries.
Failure to Conduct Quarterly Care Plan Conference
Penalty
Summary
The facility failed to conduct a quarterly care plan conference meeting with the resident or their family representative for one of the sampled residents. According to the facility's policy, a comprehensive care plan should be developed and reviewed by an interdisciplinary team, including family members or surrogates, after each comprehensive and quarterly Minimum Data Set (MDS) assessment. However, the facility was unable to provide documentation that such a meeting was conducted for the resident's quarterly comprehensive assessment. The resident in question was admitted with multiple diagnoses, including lack of coordination, severe protein-calorie malnutrition, diabetes, heart disease, anxiety, and depression. The quarterly MDS indicated that the resident is rarely or never understood and is dependent on staff for activities of daily living. Interviews with the Social Service Director and the Regional Director of Clinical Services confirmed that the family representative was not invited to the care plan meeting, which should have been conducted quarterly with the MDS assessment completion.
Failure to Reconcile Controlled Medications
Penalty
Summary
The facility failed to maintain accurate medication records and reconcile controlled medications for one of the registered nurses observed during medication administration. The facility's policy on medication administration requires that controlled substances be signed out in the narcotic book after administration. However, discrepancies were found in the narcotic reconciliation records for three residents. For Resident #1, the controlled drug record indicated 10 capsules of Gabapentin remaining, but only 8 capsules were found in the narcotic card. The LPN explained that doses were administered at 8 AM and noon, but the count was not updated. Similarly, for Resident #20, the controlled drug record showed 18 tablets of Alprazolam remaining, while the narcotic card had only 16 tablets. The LPN stated that doses were given at 8 AM and noon, but the narcotic book was not updated. For Resident #48, the controlled drug record indicated 11 tablets of Hydrocodone/Acetaminophen remaining, but only 10 tablets were found. The LPN admitted to administering a dose at 8 AM without updating the narcotic book. The Interim Director of Nursing confirmed that narcotics should be signed out in the narcotics book immediately after administration, indicating a failure to adhere to the facility's medication administration policy.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as evidenced by the presence of expired medications and improper storage of over-the-counter medication. During an observation in the Medication Room, eight expired Humalog Solution 100 UNIT/ML Pens were found with a use-by date of 12/19/24. The Assistant Director of Nursing confirmed that expired medications should not be present in the medication room. Additionally, an over-the-counter medication for muscle cramps was observed in a shared bathroom used by two residents. The Interim Director of Nursing confirmed that over-the-counter medications should not be stored in the bathroom.
Infection Control Breach During Ostomy Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during ostomy care, as observed with a Licensed Practical Nurse (LPN) identified as LPN E. The facility's hand hygiene policy mandates that all staff perform hand hygiene procedures to prevent the spread of infection, specifically before and after handling clean or soiled dressings. During an observation, LPN E was seen performing ostomy care for a resident without changing gloves and washing hands after cleaning the stoma area and before applying a new ostomy bag. This action was contrary to the facility's policy and was confirmed by LPN E during an interview. The resident involved in this incident was admitted with multiple diagnoses, including Dementia, Quadriplegia, Diabetes, and Heart Failure, and required total assistance for all activities of daily living. The resident had an ileostomy, and physician orders indicated that the ostomy bag should be changed every three days or as needed. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that the proper procedure should have included changing gloves and washing hands after cleansing the stoma before applying a new pouch, which was not followed by LPN E.
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Illustrative
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.
Illustrative
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Illustrative
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Nursing homes near Jackson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northbrooke Post Acute | 1.2 mi | ★★★★★ | 0 | 0 |
| West Tennessee Post Acute | 3.1 mi | ★★★★★ | 0 | 0 |
| Cypress Grove Post Acute | 3.2 mi | ★★★★★ | 0 | 0 |
| Mission Convalescent Home | 4 mi | ★★★★★ | 0 | 0 |
| Laurelwood Health Care Center | 5.1 mi | ★★★★★ | 5 | 1 |
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