Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

There are  92 surveys for this facility. Please select a date to view the survey results.

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Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to three complaints completed on October 2, 2019, it was determined that Maplewood Nursing and Rehab Center was not in compliance with the following Requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.

 Plan of Correction:

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

483.10(i)(3) Clean bed and bath linens that are in good condition;

483.10(i)(4) Private closet space in each resident room, as specified in 483.90 (e)(2)(iv);

483.10(i)(5) Adequate and comfortable lighting levels in all areas;

483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and

483.10(i)(7) For the maintenance of comfortable sound levels.

Based on observations and staff interviews, it was determined that the facility failed to maintain a homelike environment on one of three nursing units (third floor nursing unit).

Findings include:

Review of Resident R8's clinical record revealed the resident was admitted to the facility on August 2, 2016, with a diagnosis to include depression (mental health disorder characterized by a loss of interest in activities, causing significant impairment in daily life).

Review of Resident R9's clinical record revealed the resident was admitted to the facility on May 10, 2010, with a diagnosis to include dementia (group of thinking and social symptoms that interferes with daily functioning) and psychosis (mental disorder characterized by a disconnection from reality). Resident R9's clinical record revealed her bathing /showering days were scheduled on Wednesdays and Saturdays. Further review of Resident R9's clinical record revealed the resident had only received one bed bath from June 19, 2019, through September 25, 2019, and had refused all other scheduled bathing /showering days.

Observations on October 2, 2019, at 10:30 a.m. and at 1:10 p.m. revealed a strong pungent body odor emitting into the hallway of the north side of the third floor nursing unit. The odor was determined to be coming from resident room 325.

Interview on October 3, 2019, at 1:15 p.m. with Resident R8 who resides in room 325 bed b, where the resident stated that the odor in the room was emitting from her roommate, Resident R9, and the odor was unbearable and she said she had asked for a transfer to a different room and was told she has to wait to December.

The odor emitting from room 325 was brought to the attention of Employee E2, ADON, on October 2, 2019, at 1:45 p.m.

The facility did not create a homelike environment related to odors in the facility.

28 Pa. Code 211.12.(d)(5) Nursing services

 Plan of Correction - To be completed: 10/30/2019

Plan of Correction

Submission of this plan of correction is not a legal admission by Maplewood Nursing & Rehabilitation Center that a deficiency exists or that this Statement of Deficiencies was correctly cited. In addition, preparation and submission of this POC does not constitute an admission or agreement of any kind by the facility of the truth of any facts set forth in this allegation by the survey agency.

1. R8 receives showers on Mondays and Thursdays as part of their restorative programming.
2. Room 325 has been deep-cleaned by housekeeping.
3. A shower audit of all residents is being conducted to identify other residents who may not be bathing regularly.
4. To ensure proper practices continue:
a. All nursing staff will be inserviced regarding resident bathing schedules including alerting the assigned nurse when a shower is declined.
b. The director of nursing or designee will monitor compliance with this POC by auditing shower documentation three times per week for four weeks and then weekly for four months.
5. The results of the reviews and audits completed under this POC will be reviewed at the QAPI committee meeting for review and follow-up.

Completion Date: October 30, 2019

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