Maple Heights

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF761Dec 18, 2025

  Based on observation, interview and record review, the facility failed to ensure that staff safely stored controlled substances under double lock for 4 of 46 residents reviewed. The facility reported a census of 46 residents. Findings include: On 12/16/2025 at 8:06 AM, during an observation of the medication pass, it was discovered that several residents had controlled drugs (Ativan and Clonazepam) in the drawer with the rest of the scheduled medications. Staff C, Licensed Practical Nurse (LPN), said that they kept the scheduled doses of Ativan and Clonazepam with all the other medications and they did not have narcotic sheets to monitor daily count. […]

• No harm, potential for more than minimal, patternF880Dec 18, 2025

  Based on observations, clinical record review, staff interviews, and policy review the facility failed to use universal infection control measures (hand hygiene), and Enhanced Barrier Precautions (EBP) during catheter/wound care for 2 of 5 residents (Resident #5, and #20) reviewed. The facility further failed to monitor for the growth of legionella. The facility reported a census of 46 residents. Findings include:1. Review of Resident #20's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 14 indicating intact cognition. The MDS further revealed diagnoses of heart failure, renal insufficiency, diabetes mellitus, and a stage 2 pressure ulcer of an unspecified site. […]

• No harm, potential for more than minimal, patternF812May 9, 2024

  Based on observation, interviews and policy review the facility failed to ensure that all food items were replaced before the recommended past due date. On 5/6/24 it was discovered that a bin of flour had an open date of October of 2023. The facility reported a census of 37 residents. Findings include: During an observation of the facility kitchen on 5/6/24 at 9:25 AM it was discovered that on the lid on a bin of flour, there was a piece of brown tape with a date of 10/16/23. The Certified Dietary Manager (CDM) said that would have been the date that the bin was last filled with flour. She was not sure of the recommended shelf life for flour. […]

• No harm, potential for more than minimal, isolatedF684Dec 18, 2025

  Based on observation, resident and staff interviews, and record review the facility failed to provide increased monitoring and assessment with medication changes for 1 of 1 resident reviewed. Resident #7 had many changes to her psychotropic medications in July, and the staff failed to increase monitoring and failed to conduct an AIMS assessment (Abnormal Involuntary Movement Scale, used to monitor side effects from psychotropic medications.) The facility reported a census of 46 residents. […]

• No harm, potential for more than minimal, isolatedF689Dec 18, 2025

  Based on clinical record review, resident interview, staff interview, and policy review the facility failed to assess residents for safety while smoking for 2 of 2 residents reviewed (Resident #13, and #14). The facility reported a census of 46 residents. Findings include: 1. Review of Resident #13's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS further revealed diagnoses of heart failure, peripheral vascular disease, chronic obstructive pulmonary disease, and nicotine dependence. Interview on 12/15/2025 at 11:41 AM with Resident #13 revealed that she does smoke. Resident #13 then revealed that she has had no issues while smoking at the facility. […]