Maple Woods Manor

Inspectors wroteBased on observation, interview and record review, the facility failed store food in a sanitary manner and appropriately label and date food products.

Inspectors wroteThis citation pertains to Intake Number 3026069. Based on observation, interview and record review, the facility failed to ensure access to and answer call lights timely for three residents (#31, #49, #106) and a Confidential Group of Residents, resulting in the lack of timely care, residents' verbalizations of dissatisfaction with care and unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a clean, comfortable and home-like environment to ensure that residents' room floors were clean in rooms [ROOM NUMBERS], dining room chairs were in good repair, and TV wall hangars were securely positioned, resulting in an unclean and potentially unsafe physical environment. Findings Include: On 6/2/26 an observation was made in room [ROOM NUMBER]-2. A wall-mounted television was coming loose. The top screw in the mount was out of the wall and the mount moved freely when touched. Environment On 6/1/2026 at 9:40 AM, upon entering room [ROOM NUMBER]-2 the floor in front of the resident's bed had a large rectangular brown stained floor, approximately 3 foot x 2 foot. The remainder of the floor appeared scuffed and stained as if it needed to be rewaxed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to operationalize policies and procedure for medication storage in two of four medication rooms and two of six medication carts, resulting in a lack of cleanliness in medication storage rooms, unsecured medications, open, undated, expired, and inappropriately stored medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure palatable and appealing food for three residents (R6, R41 and R106) of five residents reviewed for food and a confidential group of residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that: 1) Ongoing surveillance for the identification of infectious organisms causing Urinary Tract Infections/UTI's to enable analysis and reporting to prevent the spread of infection and 2.) Personal Protective Equipment/PPE was worn when indicated for residents in Enhanced Barrier Precautions/EBP, resulting in a lack of compliance with infection prevention and control standards of practice. Findings Include: Infection Control On 6/03/2026 at 10:16 AM during an interview with Infection Control Practitioner/ICP C, she said she was new to the ICP role since November 2025 and someone else was the ICP before her. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent for psychotropic medications for one resident (R76) of two residents reviewed for psychotropic medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the advance directive form was completed and signed by a competent individual for one resident (#2) of 12 residents reviewed.

Inspectors wroteBased on interview and record review, the facility failed to provide documentation of adequate notice of Medicare Part A benefits non-coverage, including an Advance Beneficiary Notice of Non-Coverage for 2 residents (#20 and #101) of 3 Residents reviewed for notice of non-coverage of Medicare Part A benefits, resulting in the resident's inability to exercise the right to file an appeal in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to add interventions for weight loss for one resident (Resident #49). Record review of the facility 'Care Planning Process: Admission, Comprehensive & Short Term' policy dated 11/2017 revealed it is the policy of this facility to utilize short term care plans if indicated for short term conditions that may warrant increased assessment & observation. The purpose was to ensure prompt assessment and deliver high standard person-centered care and to communicate resident needs. To ensure the results of the comprehensive assessment are used to develop, review, and revise the resident's comprehensive plan of care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the provision of Activities of Daily Living (ADL) care to one resident (Resident #51) of five residents reviewed, resulting in lack of oral and nail care for a dependent resident.

Inspectors wroteBased on interview and record review, the facility failed to perform timely skin assessments for one resident (R17) of two residents reviewed for skin conditions, resulting in missed skin assessments and the potential to not identify changes in skin integrity.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that Restorative Nursing services were provided for 1 resident (Resident #95) of 2 residents reviewed for mobility. Findings Include:Resident #95: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #95 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: heart disease, kidney disease, diabetes, hypothyroidism, and arthritis. The MDS assessment, dated 3/25/2026, revealed the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and the resident needed partial to moderate assistance with sit to stand and transfers and walking greater than 50 feet. [...]

Inspectors wroteBased on interview and record review, the facility failed to assess and monitor weights and ensure that interventions to promote nutrition and prevent weight loss were in place for one resident (Resident #49) of 3 sampled residents reviewed for food and nutrition.

Inspectors wroteBased on observation, interview and record review, the facility failed to store and maintain respiratory equipment in a sanitary manner and ensure oxygen administration as ordered for three residents (R5, R106, R116) of three residents reviewed for respiratory care.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and operationalize policies and procedures to ensure comprehensive assessment and care of dementia for one resident (#51) of one resident reviewed resulting in a lack of implementation and revision of personalized and meaningful non-pharmacological interventions and care approaches to attain and promote the highest practicable well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication administration error rate of less than 5% when three medication errors were observed for two residents (#19 and #104) from a total of 25 observations, resulting in a medication error rate of 12%.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents were competent to sign a binding arbitration agreement prior to the resident signing it for one resident (Resident #36) of 3 residents reviewed for arbitration agreements and a Confidential Group of 10 Residents who were aware of the meaning of an arbitration agreement from a census of 104 residents. Findings Include: Arbitration A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #36 was admitted to the facility on [DATE] with diagnoses: Non-traumatic brain dysfunction, Alzheimer's disease, diabetes, heart disease, hypothyroidism, anxiety, depression and arthritis. The admission MDS assessment dated [DATE] revealed the resident had severe cognitive loss with a Brief Interview for Mental Status/BIMS score of 6/15. [...]

Inspectors wroteThis citation pertains to Intake Numbers 2685912 and 2701537. Based on interview and record review the facility failed to protect one resident's (Resident #302) right to be free from neglect, resulting in 1. Significant delay in the administration of enteral nutrition and hydration; 2. Discharge medication orders (insulin and tube feed formula) were not followed without a rationale; 3. Untimely intervention for persistently elevated blood glucose levels and lack of communication to the practitioner; and 4. An ongoing respiratory assessment and monitoring of an acute infection with antibiotic administration, which led to an unnoticed change in condition requiring hospitalization. [...]

Inspectors wroteThis citation pertains to intakes 2575094 and 2581072. Based on observation, interview and record review the facility failed to maintain a safe, functional, sanitary and comfortable environment, resulting in ambient temperatures of 84 degrees in resident care areas, no documentation of room or hall temperatures during an air conditioning outage, staff complaints of warm temperatures, residents discharging from the facility due to high temperatures, lack of available linen to provide peri-care and the increased likelihood of unmet care needs.

Inspectors wroteThis citation pertains to Intake Numbers MI00153484 and MI00153865. Based on interview and record review the facility failed to promptly assess a change in condition for one resident (Resident #501) of two residents reviewed for pain, resulting in a delay in pain treatment and discovery of bilateral femur fractures.

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor and respond to abnormally low hot water temperatures per standards of practice for the prevention and management of Legionella for a census of 111 residents, resulting in the potential for growth of infectious organisms in the facility water supply. Findings Include: FACILITY Infection Control: On 4/09/2025 at 2:11 PM, the Infection Prevention and Control/IPC Nurses J and K were interviewed. Infection surveillance was reviewed and the IPC J said she and the Maintenance Director reviewed the facilities water management program and monitoring of water for Legionella at the monthly Infection Control Committee meeting that was a part of the Quality Assurance Process Improvement meetings. IPC J said if there was a problem with the water, the Maintenance Director would tell her about it. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Code Status was documented and accessible in the medical record for 6 residents (#12, #21, #53, #79, #92 and #158) of 11 residents reviewed for Advance Directives, resulting in the potential for miscommunication of code status. Findings Include: Resident #12 Advance Directives A record review of the Face Sheet and Minimum Data Set/MDS assessment indicated Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Parkinson's disease, COPD, diabetes, kidney disease, heart failure and depression. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 14/15 and needed some assistance with care. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to complete quarterly assessments to determine the continued need for enabler bars, along with initial and monthly maintenance inspections of enabler bars, for four residents (#2, #71, #75, #76) of four residents reviewed for assist bars. Findings Include: Resident #2: On 4/9/2025 at 11:20 AM, Resident #2 was observed visiting with her son while enjoying lunch. Observed affixed to her bed were bilateral enabler bars. On 4/10/2025 at approximately 9:00 AM, a review was conducted of Resident #2's medical records and it indicated she was admitted to the facility on [DATE] with diagnoses that included, Atrial Fibrillation, Hypothyroidism, Dysphagia, Hypertension and psychotic disorder. Resident #2 required the assistance of one staff for daily cares. Further review was completed and it yielded the following results: [...]

Inspectors wroteBased on interview and record review, the facility failed to include and document residents and resident representatives in care conferences for one resident (Resident #158) of one resident reviewed for Care planning participation Findings Include: Resident #158: Care Planning On 4/08/2025 at 11:32 AM, during an interview of the Representative/wife for Resident #158, she said the resident had been at the facility for almost 3 weeks and she had not been asked to participate in a Care conference or Care planning meeting with the resident and facility. She said she was not sure how he was doing or what the plans were for him. Resident #158 confirmed he had not been included in a Care planning meeting. A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #158 was admitted to the facility on [DATE] with diagnoses: [...]

Inspectors wroteBased on interview and record review the facility failed to timely revise/update care plans for two residents (R33, R63) of five residents reviewed for care plan revision, resulting in care plans not being revised as the status and needs of the residents changed related to weight loss and pressure ulcers.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure documentation, assessment and monitoring of a hand brace/splint for one resident (Resident #53) of one resident reviewed for rehab and restorative services. Findings Include: Resident #53: Rehab and Restorative On 4/09/25 at 9:05 AM, Resident #53 was observed lying in bed in her room; she was awake and talkative. She was observed to have a splint/brace on her right hand. She said her daughter had brought it in for her and the staff assisted her in putting it on and off. The resident was asked if she performed any exercises for her right hand or arm and she said she did not. A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #53 was admitted to the facility on [DATE] and readmitted on [DATE] ith diagnoses: [...]

Inspectors wroteBased on interview and record review the facility failed to act timely on a change in mental status for one resident (Resident #11) of one resident reviewed for a change in condition. Findings Include: Resident #11: On 4/9/2025 at approximately 11:40 AM, Resident #11 was observed resting in bed, she appeared to be in good spirits. When asked how her stay has been at the facility, she stated the, staff thinks I'm nuts, the resident was asked to expound upon this, and she explained she sees cats atop her tall dresser, wrapped in her peace sign blanket. The staff tell her that she is nuts due to her observation of cats. She continued the cats resemble wolves and the staff won't grab them down for her. Resident #11 continued she does not see them on a daily basis nor do they cause her any distress. [...]

Inspectors wroteBased on interview and record review the facility failed to implement meaningful interventions to prevent the development of a pressure ulcer for one resident ( Resident #83) and ensure that skin assessments were completed timely for one resident (Resident #33) of two residents reviewed for wounds. Findings Include: Resident #83: On 4/8/20205, during initial tour Resident #83 was observed sitting in her wheelchair enjoying her lunch. On 4/5/2025 at approximately 3:00 PM, a review was conducted of Resident #88's medical records and it indicated she admitted to the facility 4/19/2024 with diagnoses that included, Heart Disease, Pressure Ulcer of Left Buttock Stage 3, Alzheimer's Disease, Dementia, Anxiety and Chronic Obstructive Pulmonary Disease. Further review revealed the following: Progress Notes: 2/21/2025 23:35: Pt (patient) has open area on LT (left) buttock measuring 0.5 x 0.4 x 0. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to 1. Follow a physician's order for enteral nutrition, 2. Notify a responsible party of changes to enteral nutrition, and 3. Complete routine cleansing and assessment/monitoring of a PEG (Percutaneous Endoscopic Gastronomy) tube for one resident (Resident #95) of two residents reviewed for tube feeding. Findings Include: Resident #95: On 4/8/2025 at 1:15 PM, Resident #95 was observed asleep in bed as her enteral feed was infusing. Observation of the pump rate showed it was infusing at 50 mL (milliliters)/hour with 150 mL flush every four hours. Review was completed of Resident #95's physician orders which indicated the following, Glucerna 1.5 at 60 ml per hour for 20 hours via pump. The Glucerna 1.5 was hung at 9:30 AM with the incorrect infusing rate. [...]

Inspectors wroteThis citation pertains to Intake Number MI00149458. Based on observation, interview and record review, the facility failed to operationalize policies and procedures for skin/wound assessments and prevent the development of pressure ulcers for three residents (Resident #1, Resident #2, and Resident #3) of three residents reviewed for wound and skin care, resulting in Resident #1's development of facility- acquired Stage III pressure ulcer to the coccyx area, five suspected deep tissue injuries on the right and left feet and pain; Resident #2's development of facility-acquired right buttock pressure wound stage II and right ischium pressure wound stage IV, and the potential for wounds to go undetected and untreated, pain and wound infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an ongoing and comprehensive nutritional assessment and timely implementation and evaluation of person-centered interventions to prevent weight loss for one resident (Resident #94) of two residents reviewed, resulting in Resident #94 experiencing a severe weight loss and the likelihood for a decline in overall health status.

Inspectors wroteBased on interview and record review, the facility failed to ensure that four Certified Nursing Assistants (CNA) (CNA S, CNA T, CNA X, and CNA Y) of five CNA's, reviewed for annual in-service education, had the required 12 hours of in-service education/training and had a performance evaluation completed annually, resulting in the potential for inadequate care and unmet resident care needs.

Inspectors wroteThis Citation pertains to Intake Number MI00140095. Based on interview and record review the facility failed to ensure that residents received care in accordance with professional standards of nursing practice for 3 residents (Resident #106, Resident #14, and Resident #10) of 10 residents reviewed for nursing assessments and physician ordered assessments, resulting in incomplete/missing/late nursing assessments and medications administered without ensuring that vital signs were in range.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a restorative nursing program was implemented and provided for 2 residents (Resident #87 and Resident #94) of 6 residents reviewed for restorative services, resulting in a lack of restorative nursing services, verbalized feelings of frustration, and concern for the decline in mobility.

Inspectors wroteThis Citation Pertains to Intake Numbers: MI00139895, MI00142125, and MI00140573. Based on observation, interview and record review, the facility failed to implement and operationalize comprehensive fall prevention procedures for one resident (Resident # 35) of seven residents reviewed, resulting in a lack of thorough investigation of falls, implementation of meaningful and planned interventions, and the likelihood for additional falls.

Inspectors wroteBased on observation, interview and record review, the facility failed to store nebulizer equipment in a sanitary manner for two residents (Resident #36 and Resident #77) of three residents reviewed for oxygen therapy, resulting in the potential for respiratory infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain an informed consent from the responsible party and signed by the physician before administering Geodon, an antipsychotic medication, and without an attempt to use nonpharmacological alternatives for one resident (Resident#28), who was exhibiting behaviors and was diagnosed and was prescribed an antibiotic for the treatment of a Urinary Tract Infection for one resident (Resident #28) of two residents reviewed for antipsychotic medication out of the total of 24 sampled residents, resulting in the administration of an antipsychotic medication without informed consent and the increased risk of serious side effects and adverse reactions from potentially unnecessary antipsychotic medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure that missing dentures were replaced in a timely manner for 1 resident (Resident #63) out of 2 residents reviewed for dental concerns from a total sample of 24 residents.