Inspection Reports for
Mapleton Post Acute
115 INGALLS ST, LAKEWOOD, CO, 80226-1815
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
9.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
83% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 17, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to provide timely Medicare Notice of Non-Coverage (NOMNC) notifications to residents and their representatives, and to assess the adequacy of discharge planning and notification processes.
Complaint Details
The complaint investigation found that the facility failed to timely inform Resident #3's representative of the end of Medicare Part A skilled services via written notice, and failed to properly document discharge planning and notification for Resident #16, including lack of written notification to the resident, representative, and ombudsman.
Findings
The facility failed to provide written Medicare Notice of Non-Coverage to Resident #3's representative when Medicare Part A skilled services ended, and failed to properly document discharge planning and notification for Resident #16, including failure to notify the resident, representative, and ombudsman in writing about the discharge details.
Deficiencies (2)
Failed to provide written notification of Medicare Notice of Non-Coverage (NOMNC) to Resident #3's representative when Medicare Part A skilled services ended.
Failed to revise and implement an effective discharge plan for Resident #16, including failure to document discharge planning, notify resident and representative in writing of discharge details, and notify the facility's ombudsman in writing.
Report Facts
Residents reviewed for beneficiary notices and appeal rights: 18
Residents reviewed for discharge planning: 18
Residents reviewed for discharge planning: 3
Residents affected by NOMNC deficiency: 1
Residents affected by discharge planning deficiency: 1
BIMS score: 5
Date Medicare Part A skilled therapy services ended: Apr 9, 2025
Date of verbal notification to Resident #3's representative: Apr 7, 2025
Date of Resident #16 discharge: Jun 5, 2025
Date of letter to Resident #16's representative: May 2, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director (SSD) | Responsible for notifying residents or representatives about Medicare Part A benefits ending and discharge coordination; interviewed regarding deficiencies |
| Director of Rehabilitation | Director of Rehabilitation (DOR) | Responsible for notifying residents or representatives about Medicare Part A benefits ending; interviewed regarding deficiencies |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Provided facility policies and interviewed regarding notification and discharge planning deficiencies |
Inspection Report
Routine
Deficiencies: 6
Date: Dec 5, 2024
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of care, discharge planning, restorative nursing services, medication storage and labeling, and infection prevention and control at Mapleton Post Acute nursing facility.
Findings
The facility failed to monitor vital signs prior to administration of blood pressure medications for three residents, failed to develop and implement effective discharge plans for two residents, discontinued restorative nursing services affecting one resident, failed to properly store and label medications, and did not maintain adequate infection control practices including improper sanitization of glucometers and inadequate cleaning of resident rooms.
Deficiencies (6)
Failed to monitor vital signs prior to administration of blood pressure medication for Residents #39, #22, and #52.
Failed to develop and implement an effective discharge plan for Residents #128 and #125.
Failed to provide restorative nursing program services to Resident #42 after July 2024.
Failed to ensure medications were securely stored and labeled, including medications left unsecured at Resident #33 and #28's bedside and unattended medications on medication carts.
Failed to ensure glucometers were sanitized appropriately between uses.
Failed to ensure resident rooms were cleaned in a sanitary manner, including inadequate disinfection times and failure to clean high-touch surfaces.
Report Facts
Sample residents reviewed: 32
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in findings related to failure to monitor vital signs prior to medication administration |
| ADON | Assistant Director of Nursing | Interviewed regarding vital sign monitoring and discharge planning |
| SSD | Social Services Director | Interviewed regarding discharge planning deficiencies |
| DOR | Director of Rehabilitation | Interviewed regarding restorative nursing program discontinuation |
| DON | Director of Nursing | Interviewed regarding medication storage and infection control deficiencies |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding medication storage and glucometer cleaning |
| RN #2 | Registered Nurse | Interviewed regarding medication left unattended at resident bedside |
| HSK #1 | Housekeeper | Interviewed regarding cleaning practices and infection control |
| HSKS | Housekeeping Supervisor | Interviewed regarding cleaning practices and infection control |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 5, 2024
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to develop and implement effective discharge plans for residents, specifically Residents #128 and #125, out of a sample of 32 residents reviewed for discharge planning.
Complaint Details
The complaint investigation found that the facility did not assist Resident #128's representative in finding a VA facility placement and failed to update the care plan or document referrals. Resident #125's discharge plan to a VA facility in another state was not supported by documented contact or coordination by the facility. Both residents' discharge preferences were not adequately followed, and social services failed to provide necessary assistance or documentation.
Findings
The facility failed to provide appropriate discharge planning processes for Residents #128 and #125, including lack of assistance with VA facility placement despite resident and family requests, inadequate documentation of discharge planning activities, and failure to coordinate with VA facilities for safe discharge. The social services department did not adequately support or communicate with residents and their representatives regarding discharge plans and benefits.
Deficiencies (1)
Failure to develop and implement an effective discharge plan for Residents #128 and #125.
Report Facts
Residents reviewed for discharge planning: 32
Residents with failed discharge planning: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director (SSD) | Named in findings for failure to assist with VA facility placement and discharge planning |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Interviewed regarding discharge planning and VA resource coordination |
| Social Services Assistant | Social Services Assistant (SSA) | Mentioned during Resident #125 interview regarding discharge preferences |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 19, 2024
Visit Reason
The inspection was conducted due to complaints regarding medication errors and pain management failures at Mapleton Post Acute nursing home.
Complaint Details
The complaint investigation revealed failures in pain management and medication administration affecting multiple residents, with substantiated findings of actual harm and widespread medication errors.
Findings
The facility failed to provide effective pain management and ensure residents received medications as ordered, resulting in actual harm to some residents. There were multiple significant medication errors affecting all five reviewed residents, and the facility's quality assurance program failed to identify and address these ongoing issues.
Deficiencies (3)
Failed to provide safe, appropriate pain management for a resident requiring such services, resulting in actual harm.
Failed to ensure residents were free from significant medication errors, resulting in minimal harm or potential for actual harm.
Failed to set up an effective quality assurance program to identify and address facility compliance concerns.
Report Facts
Residents affected: 5
Medication doses missed: 10
BIMS score: 15
BIMS score: 12
BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified nurse aide with medication authority #1 | Certified Nurse Aide with Medication Authority | Reported medications were not administered correctly and cited specific medication errors. |
| Licensed nurse practitioner #1 | Licensed Nurse Practitioner | Described procedures for handling out-of-stock medications and communication with physicians. |
| Nursing Home Administrator | Nursing Home Administrator | Discussed facility's quality assurance efforts and pharmacy issues. |
| Interim Director of Nursing | Interim Director of Nursing | Provided information on medication administration policies and issues with provider notification. |
| Director of Nursing from Sister Facility | Director of Nursing from Sister Facility | Discussed provider communication and pharmacy prescription issues. |
| Medical Director | Medical Director | Commented on pharmacy switch and provider prescription responsibilities. |
Inspection Report
Annual Inspection
Census: 68
Deficiencies: 14
Date: Jun 29, 2023
Visit Reason
The inspection was conducted as an annual recertification survey to assess compliance with regulatory requirements including resident care, abuse investigations, hospice services, staffing, medication administration, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to timely investigate abuse allegations, inadequate assistance with activities of daily living, improper pressure ulcer care, unsafe resident transfers, unsecured catheter tubing, insufficient hydration and inappropriate diet accommodations, medication errors, unsecured medication carts, incomplete hospice care coordination, inaccurate staffing data submission, and ineffective quality assurance program implementation.
Deficiencies (14)
Failed to timely and thoroughly investigate an alleged physical abuse violation for Resident #219.
Failed to provide adequate assistance with activities of daily living including showers and repositioning for multiple residents (#5, #13, #49, #62, #217).
Failed to ensure pressure ulcer treatment orders were implemented timely and care plans updated for Resident #40.
Failed to ensure two staff members were present during mechanical lift transfers for Residents #7 and #13.
Failed to secure Resident #219's indwelling catheter tubing with appropriate securement device.
Failed to provide sufficient fluids and appropriate thickened liquids to Resident #15 with history of dehydration.
Failed to ensure Resident #40 received supplemental oxygen according to physician orders (oxygen given at 6 LPM but order was for 2 LPM).
Failed to provide sufficient nursing staff to meet resident care needs based on acuity and census.
Medication error rate of 21% with errors including insulin administered after meal and medications left unattended on bedside table.
Failed to ensure medication carts were locked when left unattended.
Failed to provide food accommodating Resident #44's wheat allergy, including serving tuna casserole containing wheat and delayed gluten-free meal.
Failed to ensure hospice agency notes were accessible and no end of life care plan was developed for Resident #219 receiving hospice care.
Failed to submit complete and accurate direct care staffing information to CMS Payroll-Based Journal system.
Failed to operate an effective quality assurance program to identify and address repeat deficiencies and quality concerns.
Report Facts
Residents needing assistance with bathing: 61
Residents needing assistance with toileting: 52
Residents needing assistance with dressing: 57
Residents needing assistance with transfers: 41
Residents needing assistance with eating: 7
Medication error rate: 21
Resident census: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Failed to report abuse allegation and medication administration errors |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including abuse investigation, staffing, medication administration, and hospice care |
| CNA #1 | Certified Nurse Aide | Observed transferring residents alone with mechanical lift and leaving medication carts unlocked |
| RN #2 | Registered Nurse | Interviewed regarding catheter securement and hospice communication |
| Scheduler | Interviewed regarding staffing and agency use | |
| Dietary Manager | Interviewed regarding gluten free diet accommodations | |
| Consulting Registered Dietitian | Interviewed regarding gluten free diet accommodations | |
| Nursing Home Administrator | NHA | Interviewed regarding quality assurance and staffing |
| Corporate Executive Director | CED | Interviewed regarding quality assurance program |
Inspection Report
Routine
Deficiencies: 5
Date: Apr 19, 2023
Visit Reason
The inspection was conducted to assess the facility's infection prevention and control program, focusing on cleaning practices, disinfection of shared medical equipment, and hand hygiene compliance.
Findings
The facility failed to maintain an effective infection control program, including improper cleaning and disinfection of resident rooms and shared medical equipment, failure to follow manufacturer disinfectant contact times, and failure to offer residents hand hygiene before meals. Observations and interviews confirmed these deficiencies with minimal harm or potential for actual harm to some residents.
Deficiencies (5)
Housekeeping staff did not follow manufacturer's directions for disinfectant use, including insufficient wetting and contact time on surfaces in resident rooms.
Housekeeping staff failed to clean and disinfect all high-touch surfaces in resident rooms, such as bed controllers, TV remotes, and door knobs.
Housekeeping staff did not use the appropriate disinfectant products as required during cleaning procedures.
Certified nurse aides did not disinfect shared vital signs equipment between resident uses or did not wait the required disinfectant contact time.
Residents were not offered hand hygiene before meals in the main dining room.
Report Facts
Disinfectant contact time: 10
Disinfectant contact time: 3
Residents observed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HSKP #1 | Housekeeper | Observed failing to follow disinfectant procedures during resident room cleaning |
| CNA #1 | Certified Nurse Aide | Observed not waiting required disinfectant contact time when cleaning vital signs equipment |
| CNA #2 | Certified Nurse Aide | Observed not disinfecting vital signs equipment between residents |
| Infection Preventionist | Infection Preventionist (IP) | Interviewed regarding infection control program and deficiencies |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding infection control program and deficiencies |
| Clinical Nurse Consultant | Clinical Nurse Consultant (CNC) | Provided facility cleaning policy and interviewed about infection control practices |
| NHA | Nursing Home Administrator | Interviewed about housekeeping management and infection control expectations |
| MTD | Maintenance Director | Interviewed about housekeeping services management |
Inspection Report
Routine
Deficiencies: 3
Date: Apr 19, 2023
Visit Reason
The inspection was conducted to assess compliance with resident rights related to self-determination and choice, medication storage and labeling, and overall facility adherence to regulatory standards.
Findings
The facility failed to support resident choice regarding bathing schedules for two residents, failed to securely store medications and biologicals in locked compartments, and failed to ensure treatment carts were locked and monitored. These deficiencies posed minimal harm or potential for actual harm to residents.
Deficiencies (3)
Failed to support resident choice and self-determination for bathing schedules for two residents.
Failed to ensure drugs and biologicals were labeled and stored in locked compartments with limited access to authorized personnel.
Failed to keep treatment carts locked and monitored, exposing medications and ointments to contamination and unauthorized access.
Report Facts
Residents reviewed: 16
Residents affected: 2
Medication cards found unsecured: 39
Shower records: 1
Showers given: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed regarding bathing schedule and facility staffing |
| Director of Nursing | Director of Nursing | Interviewed regarding medication storage and bathing aide staffing |
| Clinical Nurse Consultant | Clinical Nurse Consultant | Provided facility policies and interviewed regarding medication storage |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding treatment cart security |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Aug 29, 2019
Visit Reason
The inspection was conducted due to complaints alleging failure to report and investigate abuse incidents involving residents, failure to provide adequate supervision to prevent accidents, and failure to collaborate with hospice providers for resident care.
Complaint Details
The complaint investigation was substantiated with findings that the facility failed to report abuse allegations, failed to conduct thorough investigations including interviews, failed to provide adequate supervision to prevent resident-to-resident abuse, and failed to collaborate with hospice providers for resident care documentation.
Findings
The facility failed to report an allegation of abuse involving Resident #32, did not thoroughly investigate abuse allegations involving Residents #10 and #32, failed to provide adequate supervision and behavioral management for Resident #32 who was physically and verbally aggressive, and failed to ensure consistent collaboration with hospice providers for Resident #46, resulting in incomplete documentation and care coordination.
Deficiencies (4)
Failed to timely report suspected abuse when Resident #32 grabbed another resident causing bruising.
Failed to perform and document interviews with other residents and staff during abuse investigations involving Residents #10 and #32.
Failed to provide adequate supervision and behavioral management interventions for Resident #32 who had dementia and was physically and verbally aggressive.
Failed to collaborate consistently with hospice provider to ensure accurate and timely documentation for Resident #46 receiving hospice care.
Report Facts
Residents affected: 2
Residents affected: 7
Residents affected: 1
BIMS score: 2
BIMS score: 10
Number of HCNA visits: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding investigation and reporting of abuse allegations |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Interviewed regarding reporting criteria and behavioral interventions |
| CNA #1 | Certified Nursing Assistant | Interviewed about reporting suspected abuse |
| CNA #3 | Certified Nursing Assistant | Interviewed about reporting suspected abuse |
| LPN #1 | Licensed Practical Nurse | Witnessed resident-to-resident abuse incident |
| Resident #221 | Resident | Interviewed as victim of abuse by Resident #32 |
| CNA #4 | Certified Nursing Assistant | Provided one-to-one supervision for Resident #32; lacked abuse training |
| RN #2 | Registered Nurse | Interviewed about hospice visits and coordination |
| CNA #5 | Certified Nursing Assistant | Interviewed about hospice care for Resident #46 |
| RN #3 | Hospice Registered Nurse | Interviewed about hospice visits and documentation |
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