Deficiencies (last 8 years)
Deficiencies (over 8 years)
9.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
65% worse than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
74% occupied
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 89
Deficiencies: 8
Date: Mar 7, 2025
Visit Reason
Routine inspection of Maples Health and Rehabilitation facility to assess compliance with regulatory requirements including resident care, safety, and food storage.
Findings
The facility was found deficient in multiple areas including failure to provide required Medicare notices, failure to notify residents or representatives of bed-hold policies, incomplete care planning for urinary retention, inaccurate resident code status documentation, failure to timely obtain and act on lab results for infections, failure to address significant weight loss with appropriate interventions and notifications, failure to have physician orders and care plans for CPAP use, and improper food storage practices.
Deficiencies (8)
Failed to provide Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) or denial letter at initiation, reduction, or termination of Medicare Part A benefits for one resident.
Failed to notify resident or representative in writing of bed-hold policy during hospital transfer for one resident.
Failed to develop and implement a comprehensive care plan addressing urinary care concerns including urine retention and urology referral for one resident.
Failed to ensure resident's code status preference was clear and accurate; staff failed to update DNR to full code in resident record for one resident.
Failed to timely obtain ordered labs for possible infection and notify physician of abnormal results for two residents.
Failed to ensure weight loss was unavoidable by not notifying physician and dietician, not care planning actual weight loss, and not implementing current care planned interventions for one resident.
Failed to obtain physician's order and complete care plan for use of CPAP for two residents.
Failed to store food properly after opening and did not consistently label food after opening, risking contamination.
Report Facts
Facility census: 89
Resident #65 weight loss: 7.7
Resident #43 weight loss: 11.6
Resident #43 weight loss: 5.1
Resident #43 weight loss: 10.4
Resident #43 weight loss: 17.4
Resident #43 weight loss: 6.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Business Office Manager | Named in failure to complete SNFABN form for Resident #18 |
| Social Service Director | Social Service Director | Named in failure to complete SNFABN form for Resident #18 and bed hold policy interviews |
| Administrator | Administrator | Named in failure to complete SNFABN form and bed hold policy interviews |
| Director of Nursing | Director of Nursing | Named in care planning and lab result follow-up interviews |
| Licensed Practical Nurse H | Licensed Practical Nurse | Interviewed regarding bed hold policy and urinary catheterization |
| Director of Social Services - Long Term Care | Director of Social Services - Long Term Care | Interviewed regarding bed hold policy |
| Admissions Director | Admissions Director | Interviewed regarding bed hold policy |
| Licensed Practical Nurse E | Licensed Practical Nurse | Interviewed regarding urinary tract infection lab order and symptoms |
| Certified Nurse Aide F | Certified Nurse Aide | Interviewed regarding UTI symptoms and resident eating |
| Registered Dietician O | Registered Dietician | Interviewed regarding weight loss and nutrition interventions |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding weight monitoring and CPAP care planning |
| Licensed Practical Nurse I | Licensed Practical Nurse | Interviewed regarding CPAP knowledge and orders |
| Registered Nurse J | Registered Nurse | Interviewed regarding CPAP knowledge and orders |
| MDS Coordinator | MDS Coordinator | Interviewed regarding CPAP care planning and notification |
| Dietary Aide L | Dietary Aide | Interviewed regarding food storage practices |
| Dietary Manager M | Dietary Manager | Interviewed regarding food storage practices |
| Kitchen Supervisor | Kitchen Supervisor | Interviewed regarding food storage practices |
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 1
Date: Dec 18, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding misappropriation of a resident's property, specifically a bank debit card used without permission by a facility staff member.
Complaint Details
The complaint investigation was substantiated. The resident reported unauthorized charges on his/her debit card. The accused CNA admitted to taking and using the card mistakenly, reimbursed the resident, and was suspended pending investigation.
Findings
The facility failed to protect a resident from misappropriation of property when a Certified Nurse Aide (CNA A) took a resident's debit card without permission and made fraudulent purchases totaling over $90. The CNA admitted to the unauthorized use and reimbursed the resident. The facility suspended the employee and conducted an investigation, reporting the incident to the police and Department of Health and Senior Services.
Deficiencies (1)
Failed to protect resident from wrongful use of belongings or money due to staff misappropriation of resident's debit card.
Report Facts
Unauthorized purchases: 6
Total amount: 97.68
Facility census: 96
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Employee who took and used the resident's debit card without permission |
| Director of Nursing | Director of Nursing | Interviewed resident and led investigation into misappropriation |
| Registered Nurse B | Registered Nurse | Charge nurse who notified the DON of the resident's report |
| CNA C | Certified Nurse Aide | Witnessed CNA A admitting to taking the resident's debit card |
| CNA D | Certified Nurse Aide | Witnessed CNA A admitting to taking the resident's debit card and advised reporting to DON |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided information on facility procedures for handling misappropriation allegations |
| Administrator | Administrator | Stated facility staff should follow misappropriation policy |
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 3
Date: Dec 18, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding misappropriation and exploitation of a resident's property at the facility.
Complaint Details
The complaint investigation substantiated that a CNA took a resident's debit card without permission and made fraudulent purchases. The facility reported the theft to the police and Department of Health and Senior Services and suspended the employee. Interviews and documentation confirmed the misappropriation.
Findings
The facility failed to protect a resident from misappropriation of property when a Certified Nurse Aide took the resident's bank debit card without permission and made fraudulent purchases totaling over $90. The facility suspended the employee and initiated an investigation, reporting the incident to appropriate authorities.
Deficiencies (3)
F602: The resident was not free from misappropriation as a facility staff member took the resident's debit card without permission and made unauthorized purchases totaling over $90. The facility failed to protect the resident from exploitation.
A8023: The facility did not develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents, including misappropriation of property.
A9002: The facility failed to ensure personal funds of residents were used exclusively for their benefit and only with proper authorization.
Report Facts
Facility census: 96
Unauthorized purchases total: 97.68
Number of unauthorized purchases: 6
Inspection Report
Plan of Correction
Census: 91
Deficiencies: 2
Date: Oct 4, 2024
Visit Reason
The inspection was conducted to assess compliance with resident allergies, preferences, and substitutes related to food and nutrition services at The Maples Health and Rehabilitation facility.
Findings
The facility failed to ensure that all residents received food and drink accommodations for allergies and preferences, specifically failing to provide alternative meals and drink options to residents who eat in their rooms. The facility also lacked adequate processes to inform residents of menu options and alternative meal ordering procedures.
Deficiencies (2)
F806 Resident Allergies, Preferences, Substitutes: The facility failed to provide alternative meals and drink options to residents who eat in their rooms and did not ensure residents could order alternative meals two hours prior to meal service. Residents were not provided with daily menus or adequate drink choices in their rooms.
A5001 Nutritional Needs Met, Assess Residents, Inform Doctor: The facility did not meet nutritional needs as evidenced by the deficiencies cited in F806.
Report Facts
Facility census: 91
Deficiency count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| License Practical Nurse (LPN) A | Interviewed regarding meal ordering and alternative meal policies | |
| License Practical Nurse (LPN) B | Interviewed regarding meal ordering procedures | |
| Director of Nursing (DON) | Interviewed regarding menu posting and meal policies | |
| Administrator | Interviewed regarding meal posting and facility policies |
Inspection Report
Routine
Census: 91
Deficiencies: 1
Date: Oct 4, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding providing food that accommodates resident allergies, intolerances, and preferences, including availability of appealing meal options.
Findings
The facility failed to ensure that all residents' food preferences were honored and that meal alternatives were available to residents who routinely ate in their rooms. Five residents were unable to have their preferred drink or obtain an alternative meal if not ordered two hours prior to meal service. The facility lacked a process to ensure all residents knew the daily menu and had equal access to alternative meals and drink options.
Deficiencies (1)
Failed to have a process in place to ensure all residents' food preferences were honored and meal alternatives were available to residents eating in their rooms.
Report Facts
Census: 91
Residents affected: 5
Alternative meal order timeframe: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| License Practical Nurse (LPN) A | Interviewed about alternative meal ordering and drink availability for residents | |
| License Practical Nurse (LPN) B | Interviewed about alternative meal ordering procedures and menu posting | |
| Director of Nursing (DON) | Interviewed about menu posting locations, resident rights, and staff education | |
| Administrator | Interviewed about meal posting, alternative meal ordering policy, and drink availability |
Inspection Report
Plan of Correction
Census: 95
Deficiencies: 2
Date: Feb 5, 2024
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of care, specifically focusing on medication administration and comprehensive care plans.
Findings
The facility failed to provide timely medication administration to residents, with one resident out of six sampled receiving medications late. The medication administration system and policies were reviewed and found deficient in meeting professional standards.
Deficiencies (2)
F658: The facility failed to provide medication administration per professional standards when one resident out of six sampled received medications late. The facility census was 95.
A4055: The facility did not maintain a safe and effective medication system as evidenced by the deficiency cited under F658.
Report Facts
Facility census: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician (CMT) A | Observed administering medications late | |
| Certified Medication Technician (CMT) B | Interviewed about medication administration | |
| Licensed Practical Nurse (LPN) C | Interviewed about medication administration and electronic records | |
| Administrator and Director of Nursing (DON) | Interviewed about medication administration policies and monitoring |
Inspection Report
Routine
Census: 95
Deficiencies: 1
Date: Feb 5, 2024
Visit Reason
The inspection was conducted to ensure the nursing facility meets professional standards of quality, specifically focusing on medication administration practices.
Findings
The facility failed to provide timely medication administration per professional standards when one resident out of six sampled received medications late by one hour and 35 minutes. Staff interviews and record reviews confirmed medications were administered late, and staff were unaware of the late administration.
Deficiencies (1)
Failure to have a system in place for timely administration of medications resulting in one resident receiving medications late.
Report Facts
Residents affected: 1
Facility census: 95
Medication administration delay: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician (CMT) A | Prepared and administered medications late at 10:35 A.M. | |
| Certified Medication Technician (CMT) B | Interviewed about medication administration practices and timing | |
| Licensed Practical Nurse (LPN) C | Interviewed about electronic medication records and administration | |
| Administrator | Interviewed about medication administration policies and awareness of late medications | |
| Director of Nursing (DON) | Interviewed about medication administration policies and awareness of late medications |
Inspection Report
Life Safety
Census: 85
Capacity: 120
Deficiencies: 4
Date: Jun 23, 2023
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related regulations.
Findings
The facility failed to meet several life safety requirements including improper installation of alcohol-based hand rub dispensers near ignition sources, failure to maintain smoke barrier walls, and incomplete testing of the emergency generator. These deficiencies had the potential to affect all residents, staff, and visitors.
Deficiencies (4)
K325: Alcohol-based hand rub dispensers were installed over or adjacent to ignition sources, posing a fire hazard. This deficient practice affected all resident rooms.
K372: The facility failed to maintain the smoke resistive properties of smoke barrier walls, including gaps and unsealed holes, allowing potential passage of smoke between compartments.
K918: The facility failed to complete a required four-hour load test of the emergency generator within the past three years, risking generator failure during power outages.
A2054: The smoke section walls/doors did not meet the required one-hour fire-rated separation as referenced by K372.
Report Facts
Facility capacity: 120
Resident census: 85
Inspection Report
Routine
Census: 85
Deficiencies: 8
Date: Jun 23, 2023
Visit Reason
Routine inspection of Maples Health and Rehabilitation to assess compliance with regulatory requirements including staff background checks, wound care, respiratory care, pain management, bed rail use, dietary management, and infection control.
Findings
The facility failed to ensure timely background checks for employees, follow physician orders for wound care and oxygen administration, provide appropriate pain management documentation and response, obtain proper consent and orders for bed rails, employ a qualified dietary manager, and complete required two-step tuberculosis testing for staff.
Deficiencies (8)
Failed to ensure staff checked employee disqualification list, Nurse Aide Registry, and requested Criminal Background Check prior to employee start date for two employees.
Failed to follow physician orders for wound treatment and failed to contact physician to obtain new orders for wound supplies for one resident.
Failed to follow appropriate infection control measures during wound treatment and failed to follow physician's order in timeliness of treatment for one resident with pressure injury.
Failed to ensure oxygen was administered at correct liters per minute per physician orders for one resident.
Failed to document reason for reduction in pain medication, notify physician when pain medication did not relieve pain, and failed to stop dressing removal after resident verbalized severe pain for one resident.
Failed to obtain signed informed consent and physician orders for side rails, failed to add side rails to care plan, and failed to complete side rail assessments regularly for one resident.
Failed to employ a qualified dietary manager with required certification and education.
Failed to ensure required two-step tuberculosis screening test was administered timely for seven out of ten sampled staff members.
Report Facts
Facility census: 85
Number of sampled employee files with background check issues: 2
Number of sampled staff with incomplete TB testing: 7
Resident wound size: 9
Resident wound size: 10
Resident wound size: 5
Wound vac pressure: 125
Oxygen liters per minute ordered: 2
Oxygen liters per minute observed: 6
Pain medication dosage: 5
Pain medication frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Failed to have required certification and education for position |
| Human Resources Director | Human Resources Director | Acknowledged failures in timely TB testing and background checks |
| Director of Nursing | Director of Nursing | Acknowledged failures in TB testing, oxygen administration, wound care, and bed rail documentation |
| Administrator | Administrator | Responsible for oversight of TB testing, oxygen administration, and bed rail policies |
| Registered Nurse N | Registered Nurse | Performed wound care with inadequate pain management response |
| Licensed Practical Nurse O | Licensed Practical Nurse | Provided wound care and described pain assessment practices |
| Certified Medication Technician P | Certified Medication Technician | Administered pain medication and assessed pain |
| Infection Preventionist | Infection Preventionist | Responsible for TB testing oversight |
| Dietician | Dietician | Reported Dietary Manager lacked required certification |
| Maintenance Director | Maintenance Director | Responsible for bed rail installation |
| Rehab Director | Rehab Director | Responsible for bed rail assessment and informed consent |
| MDS Coordinator | MDS Coordinator | Responsible for bed rail documentation and risk assessments |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 2
Date: Dec 15, 2022
Visit Reason
The inspection was conducted due to allegations of misappropriation and exploitation involving resident property at the facility.
Complaint Details
The complaint involved allegations of abuse, neglect, and misappropriation of resident property. The investigation substantiated these allegations based on interviews, record reviews, and bank communications.
Findings
The facility failed to protect residents from misappropriation of property when two residents had checks taken and written without their approval. Investigations revealed staff involvement and improper handling of resident funds, constituting abuse and neglect.
Deficiencies (2)
F602: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility failed to protect residents from misappropriation when checks were taken and written without resident approval.
A9002: The operator must use resident funds exclusively for the resident and only when authorized. This regulation was not met due to the misappropriation violation referenced in F602.
Report Facts
Resident census: 93
Check amount: 6000
Check amount: 3100
Check amount: 3080
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 3
Date: Oct 24, 2022
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment involving resident-to-resident abuse at the facility.
Complaint Details
The complaint investigation was substantiated as the facility failed to report and investigate allegations of resident-to-resident abuse involving Resident #1 and Resident #2 in a timely and appropriate manner.
Findings
The facility failed to report one resident's allegation of resident-to-resident abuse to the State Survey Agency within the required timeframe and failed to complete an immediate and documented investigation to protect residents during the investigation. The facility also failed to thoroughly investigate and report the results of all investigations to the appropriate officials.
Deficiencies (3)
F609: The facility failed to report one resident's allegation of resident-to-resident abuse to the State Survey Agency within the required timeframe and did not document or investigate the allegation promptly.
F610: The facility failed to complete an immediate and documented investigation and take steps to protect residents during the investigation of alleged abuse, neglect, exploitation, or mistreatment.
A8023: The facility did not develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and require reporting to the department and other authorities.
Report Facts
Facility census: 84
Deficiencies cited: 3
Plan of correction completion date: December 5, 2022 (date noted in plan of correction)
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Shirley | Administrator | Signed the statement of deficiencies on 11/17/22 |
| Director of Nursing (DON) | Observed resident's forearm and provided statements regarding abuse allegations | |
| Associate Director of Nursing (ADON) | Received reports from resident and staff about abuse allegations | |
| Certified Nurse Aide (CNA) B | Reported bruises on Resident #1 and provided interview statements | |
| Licensed Practical Nurse (LPN) A | Interviewed regarding reporting abuse allegations | |
| Licensed Practical Nurse (LPN) E | Interviewed regarding reporting abuse allegations | |
| Certified Nurse Aide (CNA) C | Interviewed regarding reporting abuse allegations | |
| Administrator | Initiated immediate investigation on 10/22/22 |
Inspection Report
Plan of Correction
Census: 76
Deficiencies: 2
Date: Sep 29, 2021
Visit Reason
The inspection was conducted to assess compliance with food and nutrition service regulations, specifically regarding the nutritive value, flavor, and appearance of food served to residents.
Findings
The facility failed to serve residents palatable and attractive food, with multiple residents and staff reporting issues such as bland, overcooked, and tasteless meals. Resident interviews and observations confirmed ongoing dissatisfaction with food quality.
Deficiencies (2)
F804: The facility failed to serve food that is palatable, attractive, and at a safe and appetizing temperature. Resident interviews and observations showed food was often overcooked, bland, and lacked seasoning.
A5003: Foods shall be prepared and served using methods that conserve nutritive value, flavor, and appearance. This regulation was not met as evidenced by the F804 deficiency.
Report Facts
Facility census: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Shipley | Administrator | Signed the inspection report and plan of correction |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 28, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with relevant regulations and CDC recommended practices.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 3, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Abbreviated Survey
Census: 65
Deficiencies: 2
Date: Aug 21, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey was conducted to assess compliance with infection control and dialysis-related care standards.
Findings
The facility failed to notify the dialysis center of a resident's positive COVID-19 status, violating dialysis care requirements. The facility was otherwise found in compliance with related emergency preparedness regulations.
Deficiencies (2)
F 698 Dialysis. The facility failed to notify the dialysis center of concerns for a resident who tested positive for COVID-19, risking spread of infection. This failure was confirmed by interviews and record review.
A4074 Nursing Care per Resident Condition. Each resident shall receive personal attention and nursing care consistent with their condition. This regulation was not met as evidenced by the F698 dialysis deficiency.
Report Facts
Facility census: 65
Compliance related regulation: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Craig Valley | Administrator | Signed the statement of deficiencies and plan of correction |
| Craig Valley | Administrator | Signed the nursing care deficiency statement |
Inspection Report
Routine
Deficiencies: 0
Date: Aug 12, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 17, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: May 27, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 3
Date: Feb 19, 2020
Visit Reason
The inspection was conducted due to a complaint investigation focusing on medication errors, food safety, and infection control at The Maples Health and Rehabilitation facility.
Complaint Details
The investigation was complaint-driven, focusing on medication administration errors, food safety concerns, and infection control practices. The complaint was substantiated as deficiencies were found.
Findings
The facility failed to maintain medication error rates below 5 percent, had inadequate food safety practices related to ice machine drainage, and did not fully implement infection prevention and control procedures, including hand hygiene and catheter care.
Deficiencies (3)
F759 Medication Errors. The facility failed to ensure medication error rates were less than 5 percent, with an error rate of 8 percent affecting two residents.
F812 Food Procurement, Store/Prepare/Serve-Sanitary. The facility failed to provide an air gap between ice machine drains and floor drains, risking contamination and food-borne illness.
F880 Infection Prevention & Control. The facility failed to establish and maintain an infection prevention program, including proper hand hygiene and prevention of contamination during catheter care.
Report Facts
Medication error rate: 8
Medication error opportunities: 25
Facility census: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse B | Licensed Practical Nurse | Administered Novolog insulin with errors noted. |
| Certified Medication Technician A | Certified Medication Technician | Administered Symbicort inhaler without instructing resident to rinse mouth. |
| Registered Nurse | Registered Nurse | Interviewed regarding medication administration and resident care. |
| Director of Nursing | Director of Nursing | Provided statements on staff expectations and infection control. |
| Dietary Manager | Dietary Manager | Interviewed about ice machine cleaning and maintenance. |
| Maintenance Director | Maintenance Director | Interviewed about ice machine maintenance and air gap requirements. |
Inspection Report
Life Safety
Census: 78
Capacity: 120
Deficiencies: 6
Date: Feb 19, 2020
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related reference documents, focusing on fire safety and hazardous areas.
Findings
The facility failed to maintain self-closing doors in hazardous areas, maintain smoke barrier walls to prevent smoke spread, and ensure power strips had functional indicator lights. These deficiencies posed potential risks to residents, staff, and visitors in the event of a fire or electrical malfunction.
Deficiencies (6)
K223 Doors with Self-Closing Devices: The facility failed to maintain self-closing devices on doors in hazardous areas, with doors propped open by wedges in the laundry and boiler rooms.
K372 Subdivision of Building Spaces - Smoke Barrier: The facility failed to maintain smoke resistive properties of smoke barrier walls, allowing gaps that could permit smoke spread throughout the building.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to maintain the electrical system when staff used surge protectors without functional indicator lights in multiple offices.
A2008 Hazardous Areas: The facility did not meet requirements for hazardous areas separation by fire-resistant construction and self-closing doors, as referenced to K223.
A2054 Smoke Section Walls/Doors: The facility did not meet requirements for smoke section walls and doors fire rating and self-closing features, as referenced to K372.
A3037 Extension Cords/Duplex Receptacles: The facility did not meet requirements for extension cords and duplex receptacles, as referenced to K920.
Report Facts
Facility capacity: 120
Census: 78
Inspection Report
Routine
Census: 78
Deficiencies: 3
Date: Feb 19, 2020
Visit Reason
The inspection was conducted to assess compliance with medication administration error rates, food safety standards, and infection prevention and control procedures at the nursing home.
Findings
The facility failed to maintain medication error rates below 5%, with an 8% error rate affecting two residents. The facility also failed to provide required air gaps on ice machine drains, risking contamination. Additionally, infection control practices were inadequate, including improper hand hygiene and glove use during pericare and catheter care.
Deficiencies (3)
Failed to ensure medication error rates were less than 5%, with two errors out of 25 opportunities (8% error rate) affecting two residents.
Failed to provide required air gap between ice machine drains and floor drains, risking contamination and food-borne illness.
Failed to use appropriate infection control procedures including hand hygiene and glove changes during pericare and urinary catheter care, and failed to prevent contamination of a nasal cannula.
Report Facts
Medication error rate: 8
Facility census: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse B | Licensed Practical Nurse | Administered insulin with timing error; commented on glove use during pericare. |
| Certified Medication Technician A | Certified Medication Technician | Administered Symbicort inhaler without instructing resident to rinse mouth. |
| Registered Nurse C | Registered Nurse | Interviewed regarding medication administration guidelines. |
| Director of Nursing | Director of Nursing | Provided expectations on medication administration and infection control practices. |
| Dietary Manager | Dietary Manager | Interviewed about ice machine cleaning practices. |
| Maintenance Director | Maintenance Director | Interviewed about ice machine maintenance and air gap checks. |
| Certified Nurse Assistant E | Certified Nurse Assistant | Observed failing to change gloves and wash hands during pericare and catheter care; contaminated nasal cannula. |
| Certified Nurse Assistant F | Certified Nurse Assistant | Assisted with pericare and catheter care; observed glove use issues. |
| Certified Nurse Assistant G | Certified Nurse Assistant | Interviewed about glove changing practices during pericare. |
Inspection Report
Life Safety
Deficiencies: 0
Date: Jan 28, 2019
Visit Reason
The inspection was conducted to assess compliance with emergency preparedness and the Life Safety Code of the National Fire Protection Association as per the 2012 edition.
Findings
The facility was found to be in compliance with emergency preparedness and met the applicable provisions of the 2012 Life Safety Code. No deficiencies or state licensure deficiencies were cited during this inspection.
Inspection Report
Annual Inspection
Census: 87
Deficiencies: 12
Date: Jan 25, 2019
Visit Reason
The inspection was an annual survey of The Maples Health and Rehabilitation facility to assess compliance with Medicare and Medicaid regulations and to identify deficiencies in care and facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide proper Medicaid/Medicare coverage notices, inadequate abuse/neglect policies, improper catheter care, failure to monitor vancomycin levels, food safety violations, and infection control deficiencies. Several residents' records and care practices did not meet regulatory requirements.
Deficiencies (12)
F582 Medicaid/Medicare Coverage/Liability Notice: The facility failed to provide completed Skilled Nursing Facility Advance Beneficiary Notices for two residents and did not properly inform residents about Medicare Part A coverage and liability.
F607 Develop/Implement Abuse/Neglect Policies: The facility failed to check the Nurse Aide Registry for federal indicators for abuse or neglect for sampled staff and lacked proper training and policies.
F690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to ensure physician orders for catheterization, proper catheter care, and monitoring to prevent urinary tract infections for multiple residents.
F757 Drug Regimen is Free from Unnecessary Drugs: The facility failed to provide routine laboratory monitoring of vancomycin levels for a resident, resulting in critical high levels and hospitalization.
F812 Food Procurement, Store/Prepare/Serve-Sanitary: The facility failed to ensure staff properly dried and stored dishes to prevent contamination; multiple instances of wet dishes were observed.
F880 Infection Prevention & Control: The facility failed to establish and maintain an effective infection prevention and control program, including failure to properly monitor tuberculosis testing and infection control procedures.
A4029 Communicable Disease-Employees: The facility failed to fully document results of two-step tuberculosis tests for seven staff members within a facility census of 87.
A4054 Safe/Effective Medication Systems: The facility failed to maintain a safe and effective medication system as evidenced by inadequate monitoring of vancomycin drug levels.
A4074 Nursing Care per Resident Condition: The facility failed to provide personal attention and nursing care consistent with residents' conditions.
A4085 Infection Control/Communicable Disease: The facility failed to use acceptable infection control procedures to prevent the spread of communicable diseases.
A7086 Equip/Utensils Air Dried, Self-Drain Utensils: The facility failed to properly dry and store utensils and equipment to prevent contamination.
A8023 Develop/Implement A/N Policies: The facility failed to develop and implement adequate abuse and neglect policies.
Report Facts
Facility census: 87
Residents discharged: 2
Vancomycin trough levels: 43.7
Vancomycin trough levels: 42
Vancomycin trough levels: 39.3
BUN level: 43
Creatinine level: 2.7
BUN level: 27
Creatinine level: 1.4
Inspection Report
Life Safety
Census: 79
Capacity: 120
Deficiencies: 4
Date: Jan 18, 2018
Visit Reason
The inspection was conducted as a Life Safety Code survey to assess compliance with fire safety and related regulations at Maples Health and Rehabilitation.
Findings
The facility failed to meet several Life Safety Code requirements including annual fuel quality testing for the emergency generator and proper separation and storage of oxygen cylinders. These deficiencies posed potential risks to residents and staff in emergency situations.
Deficiencies (4)
K918 Electrical Systems - The facility failed to conduct an annual fuel quality test on the diesel fuel for the emergency generator, risking power outage preparedness.
K923 Gas Equipment - The facility failed to separate empty oxygen tanks from full tanks, risking confusion and potential harm during emergencies.
A2010 Oxygen Storage - The facility did not use permanent racks or fasteners to prevent accidental damage or dislocation of oxygen cylinders, violating NFPA 99 standards.
A3001 Substantially Constructed/Maintained - The building was not maintained in good repair according to NFPA 101 standards applicable to facilities licensed before 1999.
Report Facts
Facility capacity: 120
Resident census: 79
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unknown Maintenance Supervisor | Interviewed regarding fuel quality test and oxygen tank storage | |
| Unknown Director of Nursing | Director of Nursing | In-serviced nursing staff on proper oxygen cylinder storage |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 6
Date: Jan 18, 2018
Visit Reason
The inspection was conducted in response to complaints alleging failure to develop and implement abuse/neglect policies, failure to check the Nurse Aide Registry for employees, failure to report alleged violations of abuse and neglect, and failure to ensure residents were free from unnecessary psychotropic medications.
Complaint Details
The complaint investigation was substantiated as the facility failed to check the Nurse Aide Registry for employees, failed to report abuse allegations for two residents, and failed to ensure residents were free from unnecessary psychotropic medications.
Findings
The facility failed to check the Nurse Aide Registry for several employees, did not report allegations of abuse for two residents to the State agency, and failed to ensure a medication regimen free from unnecessary psychotropic drugs for one resident. The facility also failed to implement adequate abuse/neglect policies and procedures.
Deficiencies (6)
F607 Develop/Implement Abuse/Neglect Policies. The facility failed to check the Nurse Aide Registry for six of nine sampled staff and did not ensure their policy directed checking all new employees for a Federal indicator.
F609 Reporting of Alleged Violations. The facility failed to report allegations of abuse for two residents to the Department of Health and Senior Services within required timeframes.
F758 Free from Unnecessary Psychotropic Medication. The facility failed to ensure a medication regimen free from unnecessary psychotropic drugs for one resident in a sample of 18.
A4029 Communicable Disease-Employees. The facility failed to complete the two-step Tuberculosis test for four staff members as required.
A4074 Nursing Care per Resident Condition. Refer to F758 for details on failure to provide appropriate nursing care related to psychotropic medication use.
A8023 Develop/Implement Abuse/Neglect Policies. Refer to F607 for details on failure to develop and implement adequate abuse/neglect policies.
Report Facts
Facility census: 79
Sampled staff for Nurse Aide Registry check: 9
Staff not checked for Federal Indicator: 6
Sample size for psychotropic medication review: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN K | Registered Nurse | Named in failure to check Nurse Aide Registry finding |
| Housekeeper L | Named in failure to check Nurse Aide Registry finding | |
| LPN M | Licensed Practical Nurse | Named in failure to check Nurse Aide Registry finding |
| DS N | Dietary Staff | Named in failure to check Nurse Aide Registry finding and TB testing finding |
| LS O | Laundry Staff | Named in failure to check Nurse Aide Registry finding and TB testing finding |
| LS P | Laundry Staff | Named in failure to check Nurse Aide Registry finding and TB testing finding |
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