Mapleton Post Acute

Resident Rights Deficiencies

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Resident Rights Deficiencies

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Services Deficiencies

Install properly constructed and protected linen or trash chutes.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Miscellaneous Deficiencies

Have restrictions on the use of highly flammable decorations.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Egress Deficiencies

Have exits that are accessible at all times.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Administration Deficiencies

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Miscellaneous Deficiencies

Provide a written emergency evacuation plan.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Smoke Deficiencies

Have an enclosure around a vertical opening shaft.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Smoke Deficiencies

Provide properly protected cooking facilities.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Egress Deficiencies

Have exits that are accessible at all times.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the installation and maintenance of electrical systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

*** CITATION TEXT NOT FOUND *** A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.

Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.1 No semi-annual fire alarm report2 Breaker lock fire panelNFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approv.. Based on observation and record review during the survey, it was determined that the facility failed to maintain emergency power systems in accordance with Section 9.1.3 of the Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems Chapter 8.1. Missing monthly December 8.4.1* EPSSs, including a.. Based on observation and staff interviews during record review, it was determined that the facility failed to maintain Fire/smoke doors in accordance with Life Safety Code NFPA 101 8.3.3.1 and 19.2.2.2.10.2.1 Boiler room penetration2 Walk-in freezer room exterior fire door doesn ' t close3 Break room self closer to the conference room (2)NFPA 101 8... Based on observation and staff interviews, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. 1 storage in means of egress basement west2 Ramp northeast ramp greater than ½ inch drop 19.2.3 Capacity of Means of Egress.19.2.3.1 T.. Based on observation, it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96. 1.Semi Annual Hood Inspection | Only 8/13/24 report available for review | no previous report availableNFPA 96 11.2.1* Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a consta.. During the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 (2012) and NFPA 90A (2012). This was evidenced by:1. Evaporative cooler use turned corridors into a plenum.NFPA 101 9.2.1 Air-Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air-conditioning, h.. Fire drill, not varied times. Corrected the following 12-month schedule on-site. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).This survey was conducted on December 31, 2024, for compliance with the National Fire Protection Association (NFPA 101.. STANDARD is not met, as evidenced by observation and staff interviews during the survey. It was determined that the facility failed to maintain sprinkler-protected hazardous areas in accordance with Life Safety Section 19.3.2.1. and 9.51 The laundry chute door shall be fire-rated.2 The laundry chute has not been inspected since 20239.5.1.2 Inlet o.. Through observation during the documentation review, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 25, and 13.1 Check dry barrel heads aged over 10 years in 20132 pendant head are being used as upright in the kitchen3 Corroded head shower south4 Painted head in room 29.. Through observation during the survey, it was determined that the facility failed to meet the Combustible Decorations requirements in accordance with NFPA 101, 19.7.5.6.The couch in the front lobby is not fire-ratedLife Safety Code Section 19.7.5.1 Draperies, curtains, and other loosely hanging fabrics and films serving as furnishings or decorations .. Through observation during the survey, it was determined that the facility failed to meet the exit signage requirements in accordance with NFPA 101, 19.2.10.1. This was evidenced by:1) The kitchen exit needs exit signs. 7.10.9.1 Inspection.Exit signs shall be visually inspected for operation of the illumination sources at intervals not to e..

A recertification survey with complaint #CO38400 was completed on 12/2/24 to 12/5/24. Five deficiencies were cited. An Emergency Preparedness survey was conducted from 12/2/24 to 12/5/24. No deficiencies were cited. Based on observation and interviews, the facility failed to ensure all drugs and biological used in the facility were properly stored and labeled in two out of two units.Specifically, the facility failed to:-Ensure medications that were self administered were stored securely at the bedside for Resident #33;-Ensure a medication storage room was securely locked;-Ensure medications that were not administered were not left unsecured at Resident #28' s bedside; and,-Ensure medications were not left unattended on medication and treatment carts.Findings include:I. Facility poli.. Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to prevent the development and transmission of disease and infection on two out of two units.Specifically, the facility failed to:-Ensure glucometers were sanitized appropriately between uses; and,-Ensure the resident' s rooms were cleaned in a sanitary manner.Findings include:I. Ensure glucometers were sanitized appropriately between usesA. Professional referenceThe Centers for Disease Cont.. Based on observations, record review and interviews, the facility failed to ensure each resident with limited range of motion received appropriate treatment and services to increase range of motion (ROM) and/or prevent further decrease in ROM for one (#42) of two residents reviewed for restorative services out of 32 sample residents.Specifically, the facility failed to ensure Resident #42 was provided with a restorative nursing program to maintain and/or prevent deterioration of her current level of function and mobility.I. Facility policy and procedureT.. Based on observations, record review and interviews, the facility failed to provide services for three (#39, #22 and #52) of five residents out of 32 sample residents according to professional standards of practice.Specifically, the facility failed to monitor vital signs prior to the administration of a blood pressure medication for Resident #39, Resident #22 and Resident #52.Findings include:I. Professional referenceAccording to Khashayar, F., Arif, J. (2023). Beta Blockers. Stat Pearls. National Library of Medicine, was retrieved on 12/9/24 from https://www.ncbi.nlm.nih.g.. Based on record review and interviews, the facility failed to develop and implement an effective discharge plan for two (#128 and #125) of three residents reviewed for discharge planning out of 32 sample residents.Specifically, the facility failed to provide an appropriate discharge planning process for Resident #128 and #125. Findings include:I. Facility policy and procedureThe Discharge Planning policy and procedure, not dated, was provided by the nursing home administrator (NHA) on 12/5/24 at 11:08 a.m. It read in pertinent part, "It is the policy of this facility that disc..