Maple Lawn Medical Care Facility

Inspectors wroteBased on observation, interview, and record review the facility failed to implement interventions to prevent accidents for two residents (#2, #6) of three resident reviewed for accidents resulting in major injury (fracture and brain bleed) and hospitalization for resident #2. Findings Included: Resident #2 Review of the medical record demonstrated R2 was admitted [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), dementia, repeated falls, constipation, psychotic disorder with delusion, hypothyroidism (low thyroid hormone), vitamin D deficiency, chronic kidney disease, depression, gastro-esophageal reflux, osteoarthritis (arthritis that occurs when flexible tissue at the end of bones wears down), chronic pain, hyperlipidemia (high fat content in blood). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide notice of discharges and transfers, to the representative of the Office of the State Long-Term Care Ombudsman. According to an email from the Long-Term Care Ombudsman, received on 8/22/25, the facility had not been sending notices for transfers and discharges and that they did not have any notices on record for 2024 or 2025. On 8/26/25 at 12:03 PM, the Nursing Home Administrator (NHA) was asked who is responsible for notifying the ombudsman of discharges and at 12:32 PM NHA reported that the ombudsman is emailed on a monthly basis either by herself or by the social worker. When asked to provide the monthly emails dating back to their last annual survey, NHA reported that they only had 2 on file. Those emails were provided and were dated 8/14/25 and 8/26/25. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure clinical rationale was documented by the provider for ongoing use of an as needed (PRN) anti-anxiety medication beyond 14 days, for one resident (resident #6) of four residents reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to complete a Significant Change in Status Assessment (SCSA) for one resident (#91) of 15 resident's Minimum Data Set (MDS) reviewed. Findings Included:Resident #91 (R91)Review of the medical record demonstrated R91 was admitted to the facility 01/31/2025 with diagnoses that included atrial fibrillation, hypothyroidism (low thyroid hormone), gastroesophageal reflux, chronic pain, sacral pressure ulcer, osteoarthritis (arthritis that occurs when flexible tissue at the end of bones wears down), hyperkalemia (high level of potassium in blood), bradycardia (heart rate below 60 beats per minute), history of pace maker, and urinary retention. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/07/2025 revealed a Brief Interview for Mental Status (BIMS) of 13 (cognitively intact) out of 15. [...]

Inspectors wroteThis citation pertains to intake number MI00152699. Based on interview and record review the facility failed to ensure one out of three residents (Resident #2) was able to exercise resident rights and be treated with respect and dignity. Findings Included: Review of the facility documents revealed Resident #2 (R2) had resided at the facility since [DATE], and had a diagnosis of dementia and behavior disturbances. R2 was deceased at the time of the onsite investigation. Review of a facility investigation revealed that on [DATE] Medical Assistant (MA) C reported that Licensed Practical Nurse (LPN) D entered R2's room while she was in the room to administer medications to R2. MA C reported that R2 was lying flat in bed when LPN D gave R2 a pill, and told R2 that was a new stomach pill that he needed to take. [...]

Inspectors wroteThis survey pertains to intake MI00146629. Based on observation, interview and record review, the facility failed to develop and implement person-centered care approaches for one resident (Resident #1) with dementia of three reviewed.

Inspectors wroteBased on interview and record review the facility failed to provide appropriate infection surveillance for all residents (100 current residents) and take appropriate actions to track, trend, and formulate corrective actions to decrease the spread of nosocomial infections in the facility. Findings Included: During an interview on 08/15/2025 at 09:32 a.m. Infection Control Preventionist (ICP) C explained that he had been in his current position since February of 2024 and was responsible for the data collection and review of information regarding infections in the facility. ICP C explained that he reviewed the data and would identify trends that potentially required interventions to prevent further spread of infection. ICP C explained that the Infection Control Committee met a monthly, through the Quality Assurance Committee, and a report was provided to the committee monthly. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate staffing to provide restorative/mobility services and choice of shower frequency, in a sample of 20 residents and a census of 100 residents, resulting in resident choices not honored, unmet goals, and the likelihood for functional decline.

Inspectors wroteBased on observation, interview, and record review the facility failed to allow one out of two residents (R9) to relocate to a chosen room of 2 residents reviewed for choices resulting in emotional distress manifested as frustration, anger, and depression.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide restorative services to maintain mobility, in two of two residents reviewed for mobility (Resident #98 & #44), resulting in anxiety and unmet goals.

Inspectors wroteBased on observation, interview, and record review the facility failed to include daily nursing total numbers and actual hours worked on the posted Daily Nurse Schedule, which was available for 100 current residents and family/visitors. Findings Included: During an interview on 08/15/2024 at 12:49 a.m. Nursing Staff Scheduler F was asked where the facility daily nursing hours were posted in the facility. Nursing Staff Scheduler F explained that a nursing staff schedule was posted outside of the nurse managers office. Nursing Staff Scheduler assisted surveyor locating the posting of the facility daily nursing hours. During that time, it was observed a document was posted entitled Daily Nurse Schedule, dated 08/15/2024. The document demonstrated names and shifts of person that were to work that date. [...]

Inspectors wroteThis Citation Pertains To Intake MI00140863 Based on observation, interview and record review the facility failed to ensure one resident (Resident #3) was free from abuse of three reviewed, resulting in Resident 3 being abused by a staff member.

Inspectors wroteThis Citation Pertains To Intake MI00140863 Based on observation, interview, and record review, the facility failed to report allegations of abuse for one (Resident #3) of 3 reviewed for abuse reporting, resulting in known allegations of abuse that were not reported timely to the facility Administrator and/or Director of Nursing . This deficient practice leaves the potential for further allegations of abuse to go undetected and unreported, allowing the opportunity for further abuse to continue.

Inspectors wroteBased on observation, interview, and record review the facility failed to inform and or have ongoing communication with residents regarding their rights as expressed during the confidential group meeting held on 06/07/23 for 15 of 15 of the participants resulting in the potential for rights to be violated, misunderstood, and the inability of the Residents to make informed decisions regarding their rights Findings Included: During a confidential resident council meeting with the state surveyor on 6/27/2023 at 2:00 PM, 15 out of 15 residents who were in attendance stated that they did not know where they could find the information on resident rights, and all 15 residents concurred that they did not know where it was posted. All 15 residents concurred that staff had not ever gone over resident rights with them. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 15 out of 15 resident, who attended a confidential group meeting, were knowledgeable of their resident rights regarding the Ombudsman contact information, state agency contact information, how to file a complaint with the state agency, and the state agency survey results, resulting in the potential for resident to not be able to exercise their rights. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 15 out of 15 resident, who attended a confidential group meeting, were knowledgeable of their resident rights on how to file a grievance and complaint, resulting in the potential for residents grievances and complaints to go unresolved. Findings Included: During a confidential resident council meeting with the state surveyor on 6/27/2023 at 2:00 PM, 15 out of 15 residents who were in attendance stated that they did not know where they could find the information on resident rights regarding how to file a grievance, where the grievance forms were located, what the process was to file a grievance. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate completion of advance directive information for 1 (Resident #30) of 1 resident reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time) resulting in the potential for a resident's preferences for medical care to not be followed by the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of three residents (Resident #40) was assessed for removal of a Foley catheter (tube inserted into the bladder to drain urine into a drainage bag), and document a clinical rational that demonstrated the necessity for the catheter, resulting in the potential for infection and/or long-term urinary incontinence. Findings Included: Per the facility face sheet Resident #41 (R41) was admitted to the facility on [DATE]. Diagnoses included personal history of other diseases of urinary system, and obstructive and reflux uropathy (blockage/trouble urinating). [...]

Inspectors wroteBased on interview and record review, the facility failed to 1) ensure timely follow up on pharmacy recommendations for one (Resident #66) of six residents reviewed for unnecessary medications and 2) ensure the facility's policy included timeframes for each step of the Medication Regimen Review (MRR), resulting in the potential for unnecessary medications and untimely follow up to pharmacy recommendations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately monitor and document involuntary movements, in one of five residents reviewed for high-risk medications (Resident #35), resulting in an inaccurate monitoring and the potential for unmet needs.