Maple Crest Manor

In the surveyor’s words

From the most serious findings on record at Maple Crest Manor, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 25, 2021

  Based on observations, interviews, and record review the facility failed to keep 1 of 5 wandering residents safe from injury from an unsupervised steam table in the dining room (Resident #40). Wandering residents still able to access steam table with little to no intervention measures in place.The facility reported a census of 40 residents. Findings included: 1. The Minimum Data Set (MDS) assessment for Resident # 40 dated 05/27/20, included a [DIAGNOSES REDACTED]. The MDS reflected the Resident # 40 wanders daily. The MDS recorded Resident is independent ambulatory without supervision. The Care Plan for Resident # 40 dated 5/20/20, directed staff the resident needs directional cues for ambulation, and a Wander Alert bracelet. […]

• No harm, potential for more than minimal, patternF805Jul 9, 2026

  Based on observation, document review, policy review, and staff interview, the facility failed to prepare the correct puree servings and serve the dietician approved pureed menu to 4 of 4 residents reviewed (Resident #13, #19, #32 and #36). The facility identified a census of 38 residents. Findings include:The Week Five 5/5/26 Dietician Approved Pureed Menu for lunch on 7/7/26 listed the following:a. 3 ounce (oz) lemon garlic pork loinb. 4 oz Pasta Alfredoc. 4 oz broccolid. 1 slice garlic toaste. 1 square pumpkin earthquake cake.Observation on 7/7/26 at 11:25 AM, Staff D, Dietary stated she planned to prepare five servings of pork loin. Staff D measured out 16 oz of pork loin, placed in the blender and added two ladles of gravy to the blender and blended. […]

• No harm, potential for more than minimal, patternF812Jul 9, 2026

  Based on observation, 2017 United States (US) Food and Drug Administration (FDA) Food Code, document review, policy review, and staff interview the facility failed to ensure food was dated when stored, maintain clean equipment per the cleaning schedule, prevent soiled gloves from contacting food, failed to wash hands between glove changes and before starting new tasks, maintain appropriate cold beverage temperatures, and ensure staff entering the kitchen wore hairnets. The facility identified a census of 38 residents. Findings include: During an initial visit to the kitchen on 7/6/26 at 9:32 AM the following observations were made:a. […]

• No harm, potential for more than minimal, patternF880Feb 25, 2021

  Based on observation, interviews, and record review the facility failed to follow the Centers for Disease Control and Prevention (CDC) recommendation for hand hygiene after contact with residents and the resident's environment, staff failed to follow Guidance for [DIAGNOSES REDACTED]-CoV-2 (COVID-19) Point-of-Care Testing dated 02/02/21, failed to screen resident according to Preparing for COVID-19 in Nursing Homes Updated 10/20/20. The facility reported a census of 40 residents. Findings included: 1. During a random observation on 02/16/21 at 01:30 p.m., Staff A Certified Nurses Aid (CNA) went in Resident # 22's room in quarantine, removed the full body lift from next to the bed, and pushed it out in the hall and up into room [ROOM NUMBER]. […]

• No harm, potential for more than minimal, isolatedF550Jul 9, 2026

  Based on observation, interview, record review, and policy review the facility failed to ensure a staff member treated a resident with dignity and respect regarding an interaction between the resident and Staff O, Certified Nursing Assistant (CNA) for 1 of 3 sampled residents reviewed for dignity (Resident #27). The facility reported a census of 38 residents.Findings include:Review of Resident #27's Minimum Data Set (MDS) dated [DATE] documented the resident had short-term and long-term memory problems and had severely impaired cognitive skills for daily decision-making. The assessment indicated the resident experienced physical and verbal behavioral symptoms directed toward others on 4 to 6 days during the 7-day look-back period. […]