Maplewood Health Care Center

F-F600 was received on 2/28/2025, and the Removal Plan was validated onsite by the surveyor on 3/3/2025 through policy review, medical record review, observation, review of education records, and staff interviews.

The 300 hall Charge Nurse verified the 100 hall medication count and keys at 7:28 AM on 2/23/2025 from

the 7:00 PM - 7:00 AM 100 hall charge nurse after being informed that assigned nurse would be arriving soon. This 300 Hall Charge Nurse then returned to 300 hall to continue medication administration on hall 300.

From approximately 8:15 AM to 10:15 AM on 2/23/2025, the treatment nurse was noted providing treatments

on the 100 hall for various residents, to include Resident #2.

Following completion of care for other unforeseen acute resident conditions and 300 hall medication administration, the 300 hall Charge Nurse alerted the Director of Nursing that the scheduled nurse that was believed to be arriving late for the 100 hall, had not arrived. The Registered Nurse charge nurse from hall 200 attempted to notify the staffing coordinator/scheduler at approximately 12:12 PM on 2/23/2025.

The 300 Hall Charge Nurse began medication administration for the 100 hall until the Nurse Manager on call arrived at 1:49 PM on 2/23/2025.

On 2/23/2025 at approximately 12:40 PM, the Nursing Home Administrator was made aware that the scheduled 100 hall 7:00 AM -7:00 PM shift charge nurse had not arrived to scheduled shift. The Director of Nursing notified the Regional Director of Clinical Services at approximately 1:40 PM.

At approximately 2:00 PM and 3:40 PM on 2/23/2025, a governing body meeting was held with attendance including the Director of Nursing, Administrator, Regional Director of Clinical Services (RDCS), Chief Operating Officer, and [NAME] President (VP) of Clinical Services to discuss findings, root cause, plan of correction, education, and development and implementation of a Performance and Improvement Plan. The Root Cause was determined to be the Charge Nurse failure to report to duty, gap in employee communication, and unforeseen patient acuity that coincided with the 300 Hall nurse's medication pass leading to the delay.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 9 445412 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 445412 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Maplewood Health Care Center 100 Cherrywood Place Jackson, TN 38305

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Education was provided on 2/23/2025 to the RDCS, Administrator, and Director of Nursing by the VP of Clinical Services and the Chief Operating Officer regarding On-Call Procedures, which included but were not Level of Harm - Immediate limited to the specific details of rotating the Administrator, Director of Nursing, or Assistant Director of jeopardy to resident health or Nursing as designated, verifying the facility following each 7:00 AM to 7:00 PM shift change to ensure safety adequate and appropriate staff to administer resident medications and to monitor/assess residents needs and conditions, Communication, Procedure for delayed/missed medication, Assessments and Notifications, Residents Affected - Few Reinstructed regarding Abuse Prohibition and Neglect, Staffing Procedures and adjustments which included but were not limited to specific details of shift relief has not arrived by their scheduled shift time, the off going nurse will promptly contact the Nurse Manager on call. The Nurse Manager on call will coordinate charge nurse coverage with the staffing scheduler. 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, and procedure of notifying the physician following assessing all potentially affected residents for further direction of action related to delayed or missed medication administration, and ongoing monitoring plan to prevent recurrence.

On 2/23/2025 at 2:47 PM, Resident #2's blood glucose level was assessed at 313 mg/dl by the 300 Hall Charge Nurse with 8 units of Novolin R per sliding scale administered per physician order; at 5:32 PM, Resident #2's blood glucose level was assessed by the on call Nurse Manager at 332 mg/dl with 8 units of Novolin R administered per sliding scale

Resident #2 noted with physician order stating metFORMIN HCL [hydrochloride] ER [extended release] Oral Tablet Extended Release 24 Hour 500 MG (Metformin HCL) Give 500 mg by mouth two times a day for DM.

On 2/23/2025, the 300 hall Charge Nurse administered the Metformin 500 mg dose to Resident #2 at 2:44 PM. Metformin 500 mg was also administered to Resident #2 by on call Nurse Manager for next scheduled dose following Physician notification of delayed and missed morning medication administrations at 5:28 PM.

The Charge Nurse administered 25 units of Insulin Glargine as ordered at 7:46 PM on 2/23/2025 with a blood glucose of 402 mg/dl.

All 100 hall residents, to include Resident #2, were evaluated for delayed medications by the Director of Nursing and Licensed Practical Nurse. All applicable Residents blood glucose levels, to include Resident #2, were assessed per accucheck on 2/23/2025 upon arrival of Director of Nursing to facility between 2:00 PM and 3:00 PM with physician notification completed.

The Medical Director was notified by the DON on 2/23/2025, for notification of all delayed medications and missed accuchecks and insulin administration with current blood glucose levels obtained. The Physician was notified of all medications showing missed administration with verbal agreement provided to administer all medications at this time; notified of all missed accuchecks and insulin administrations with current blood glucose levels with no further orders. The Medical Director was included in adhoc [for this situation] Quality Assurance and Performance Improvement (QAPI) meeting on 2/23/25 with attendance including Administrator, Director of Nursing, and Regional Director of Clinical Services for discussion of notification of resident assessment findings, to include Resident #2, reviewed and approved Performance Plan developed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 9 445412 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 445412 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Maplewood Health Care Center 100 Cherrywood Place Jackson, TN 38305

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 2/23/2025 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, Level of Harm - Immediate reinstructed regarding abuse prohibition and neglect, and staffing procedures which details included but not jeopardy to resident health or limited to the facility procedure/protocol of notifying the Nurse Manager on call if a clinical staff member does safety not report to their scheduled shift in order for coverage to be coordinated. All off duty, to include PRN (as needed) or Agency, licensed nurses will receive this education prior to the beginning of their next shift. Residents Affected - Few

The Director of Nursing and Regional Director of Clinical Services completed a Medication Administration audit for all residents on 2/23/2025.

On 2/24/2025 at 7:15 pm, 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. Reviewed all findings from 2/23/2025 and developed Performance Improvement with agreement to continue with action and plan developed.

Adhoc QAPI meeting held on 2/26/2025 with the Medical Director to share Removal and in agreement with Plan of Correction and Monitoring in place effective 2/23/2025.

The Director of Nursing and/or Assistant Director of Nursing will audit medication administration competition. Monitoring will occur twice daily x (times) 7 days, then twice daily during business days x 3 weeks, then weekly thereafter during morning clinical meeting. If substantial compliance is not met, re-education will be initiated, and audits will be reinitiated.

The Director of Nursing will report the findings to the monthly QAPI Committee meeting.

Removal plan was discussed and approved by Medical Director 2/25/25, 2/26/25, and 2/28/25.

The Administrator will ensure the removal plan is completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 9 445412