Maple Manor Rehab Center

Inspectors wroteBased on interview and record review, the facility failed to ensure a registered nurse was designated to serve full-time as the Director of Nursing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 05/27/2026 at 8:49 AM in an interview regarding date marking, Dietary Manager (DM) E indicated every food item is dated the day opened, and is discarded within three days. On 05/27/2026 at 8:50 AM observed sliced cheese wrapped in plastic with a facility marked date of 5/18 in the walk in cooler. On 05/27/2026 at 9:05 AM observed the three compartment sink drain lines for the wash, rinse, and sanitize basins all connect to a common drain line and discharge to the floor with no air gap. On 05/27/2026 at 9:08 AM observed a piece of cloth wrapped around the rinse and sanitizer faucet base. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility. Based on interview and record review, the facility failed to consistently implement a comprehensive infection control program that conducted proper facility surveillance and utilized maps or other processes to readily identify trends of infections, resulting in missed opportunities for corrective actions and the potential for spread of infectious organisms throughout the facility affecting the entire census of 36 residents. [...]

Inspectors wroteBased on interview and record review the facility failed to maintain a continuous Antibiotic Stewardship Program that includes monitoring antibiotic usage, tracking resistance, preventing emergence of resistance, and following protocols for antibiotic use, which has the potential to affect all residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update the care plan for one (R4) of one resident reviewed for care plans to include R4's pressure ulcer or prescribed interventions. On 7/16/2025 at 9:03 AM, R4 was observed sitting up in bed awake and alert with some confusion. There was no pressure relieving mattress in place or other pressure relieving measures observed. R4 consented to receiving incontinence care from CNA (certified nursing assistant) C. During care, a dime-sized shallow crater-like opened area was observed on the resident's coccyx area. There was dried white cream observed to be covering the surrounding area. CNA C reported the resident developed the pressure ulcer a couple weeks ago and a cream was being applied to the area. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure adequate delivery of activity of daily living (ADL) care for two residents (R9 and R23) out of three residents reviewed for hygiene resulting in unkempt facial hair and overgrown fingernails. R9 On 7/15/2025 at 11:50 a.m., R9 was observed in the therapy room with long facial hair and long dirty untrimmed fingernails. R9 was not available for interview. On 7/16/2025 at 10:24 a.m., R9 was observed with long facial hair and long dirty untrimmed fingernails. During the interview the resident confirmed not being asked to get shaved not even on scheduled shower days and been wanting to be shaved and to have nail care provided. The resident said before coming to the facility his beard and mustache were trimmed neat. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement pressure ulcer care for one (R4) of one resident reviewed for pressure ulcers resulting in R4 developing a stage two pressure ulcer (open sore, partial thickness loss of skin, presents as shallow crater) on the coccyx when prescribed pressure ulcer skin treatments that included a Low-Air-Loss (LAL) mattress were not implemented. On 7/16/2025 at 9:03 AM, R4 was observed sitting up in bed awake and alert with some confusion. There was no pressure relieving mattress in place or other pressure relieving measures observed. R4 consented to receiving incontinence care from CNA (certified nursing assistant) C. During care, a dime-sized shallow crater-like opened area was observed on the resident's coccyx area. There was dried white cream observed to be covering the surrounding area. [...]

Inspectors wroteBased on interview and record review the facility failed to accurately record the use of an antibiotics for 1 of 1 resident (R1) on the facility's antibiotic surveillance log resulting in R1's use of antibiotics from 3/26/25 - 5/23/25 not recorded on the facility log and an incorrect facility infection rate for the months April, May, and June of 2025. On 7/17/25 at 10:01 AM the facility's Infection Prevention Control Program was reviewed with Registered Nurse and Infection Preventionist (RN) G. Antibiotic Stewardship was reviewed for R1. According to R1's Electronic Health Record (EHR), R1 admitted to the facility with diagnoses that included Urinary Retention and required a supra-pubic catheter (flexible tube surgically inserted through the lower abdomen into the bladder to drain urine). On 3/18/25 R1 was diagnosed with a UTI (urinary tract infection). [...]

Inspectors wroteBased on interview and record review the facility failed to provide the influenza and pneumococcal immunizations/vaccines for one (R4) of five residents resulting in R4 not receiving these immunizations/vaccines that were consented to in January 2025. On 7/17/2025 at 11:00 AM the facility's Infection Prevention Control Program was reviewed with Registered Nurse and Infection Preventionist (RN) G. Immunizations/vaccines were reviewed for R4. According to R4's Electronic Health Record the resident admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease. On 1/7/2025 the resident and the resident's Legal Guardian (LG) signed consents for the resident to receive the pneumococcal and influenza vaccines. There was no documentation to support the resident received those vaccines. [...]

Inspectors wroteBased on interview and record review the facility failed to provide the Covid-19 vaccine for one (R4) of five residents resulting in R4 not receiving the Covid-19 vaccine that was consented to in January 2025. On 7/17/2025 at approximately 11:00 AM the facility's Infection Prevention Control Program was reviewed with Registered Nurse and Infection Preventionist (RN) G. Immunizations/vaccines were reviewed for R4. According to R4's Electronic Health Record, the resident admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease. On 1/7/2025 the resident and the resident's Legal Guardian (LG) signed a consent for the resident to receive the Covid-19 vaccine. There was no documentation to support the resident had received the Covid-19 vaccine. RN G was queried and said, The resident was screened and determined to be eligible for Covid-19 vaccine. It was missed. [...]

Inspectors wroteThis citation pertains to intake MI00149794. Based on interview and record review, the facility failed to ensure adequate discharge planning was in place for one resident (R400) of three residents reviewed for discharge planning, resulting in R400/representative not educated on the administration of an injectable anticoagulant (a highest-risk medications used thin blood and prevent blood clots), the potential for medical complications (bleeding) and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove expired, undated, unlabeled food from the kitchen walk-in cooler, freezer, pantry and resident refrigerators. This deficient practice had the potential to affect all the residents who consumed food from the kitchen and resident refridgerators, resulting in the increased potential for food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to establish a comprehensive Infection Control Program that conducted proper facility-wide surveillance and consistently reviewed microbiology summary reports.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess for self-medication administration prior to leaving medications at bedside for one resident (R12) out of two residents reviewed during medication administration. Findings Included: Resident #12(R12) Review of the medical record demonstrated R12 was admitted to the facility 06/25/2023 with diagnoses that included congestive heart failure, hypertension, cardiomyopathy (disease of the heart muscle that makes it hard for the heart to pump blood), atrial fibrillation, venous insufficiency, chronic obstructive pulmonary disease (COPD), and Gout (build up of uric acid in bone joints). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/16/2024, demonstrated a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1. Properly secure protected health information for one resident (R29) out of one resident reviewed for privacy of medical information, resulting in the potential for unauthorized disclosure, access and modification 2. Provide a privacy curtain for one resident (R8) out of one resident reviewed for privacy resulting in resident dissatisfaction and a lack of privacy.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide Activities of Daily Living (ADL's), including bathing/showering/shaving for one dependent resident (R1) out of two residents reviewed of ADL completion. Findings Included: Resident #1 (R1) Review of the medial record demonstrated R1 was admitted to the facility 06/27/2018 with diagnoses that included athetoid cerebral palsy (a movement disorder that causes involuntary muscle movements), hypertension, peripheral vascular disease (PVD) hyperlipidemia (high fat levels in the blood), abnormalities of gait and mobility, muscle weakness, and major depression. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/08/2024, demonstrated a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 09/25/2024 at 01:31 p.m. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to coordinate hospice services for one resident (R9) out of one resident reviewed for coordination of hospice services resulting in the potential for care not being provided to resident receiving hospice services and the potential for residents not to be fully informed of hospice services provided. Findings Included: [...]

Inspectors wroteBased on interview and record review, the facility failed to effectively develop and implement, and maintain a Quality Assurance and Performance Improvement (QAPI) program that was fully sustained during transitions in leadership and regularly reviewed and analyzed data, resulting in the potential for missed opportunities to identify and prevent deviations of care delivered to facility residents.