Maple Knoll Village

In the surveyor’s words

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

• Actual harm, isolatedF689May 11, 2026

  Based on record review, resident and staff interview, and facility policy review, the facility failed to safely and properly position a resident during incontinence care. Actual harm occurred on 04/08/26 when Certified Nurse Assistant (CNA) #525 rolled Resident #10 in bed away from her and the resident fell onto the floor sustaining a closed fracture of left femur and a laceration of upper forehead which required sutures. This affected one (Resident #10) of one resident reviewed for falls. The facility census was 68 residents. Findings include: Review of the medical record for Resident #10 revealed admission date of 05/22/23 with diagnoses including chronic obstructive pulmonary disease, diabetes mellitus type two, and morbid obesity. […]

• No harm, potential for more than minimal, widespreadF812May 11, 2026

  Based on observation, staff interview, and review of the facility policy, the facility failed to store and prepare food in a sanitary manner to prevent contamination and spoilage. This had the potential to affect all residents except for one (#68) that did not consume food from the kitchen due to a diet of nothing by mouth. The facility census was 68 residents. Findings include: 1.Observation on 05/04/26 at 9:43 A.M. with Executive Chef (EC) #6051 revealed the walk- freezer in the main kitchen located in the basement revealed it contained the following items: a box of strawberry pastries opened and exposed to air, two bags of undated dinner rolls, a box of pork chops opened and exposed to air. Interview on 05/04/26 at 9:43 A.M. […]

• No harm, potential for more than minimal, isolatedF677May 11, 2026

  Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure residents received adequate grooming and nail care. This affected two (Residents #44 and #70) of two residents reviewed for activities of daily living (ADLs). The facility census was 68 residents. Findings include: 1. Review of the medical record for Resident #44 revealed an admission date of 04/01/22 with diagnoses including dementia, traumatic subdural hematoma and hypertension. Review of the Minimum Data Set (MDS) assessment for Resident #44 dated 03/16/26 revealed the resident had severe cognitive impairment and was required maximal assistance with grooming and hygiene. […]

• No harm, potential for more than minimal, isolatedF761May 11, 2026

  Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure insulin vials were properly labeled and stored. This affected two (Residents #2 and #25) of 17 residents with medications stored in the Three North medication cart. The facility census was 68 residents. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 01/14/25 with diagnoses including diabetes mellitus type two and chronic kidney disease. Review of the physician's orders for Resident #2 revealed an order dated 06/08/25 for Lantus insulin 10 units at bedtime. […]

• No harm, potential for more than minimal, isolatedF677Sep 25, 2025

  Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure staff provided timely incontinence care. This affected two (Residents #15 and #16) of three residents reviewed for call light response. The facility census was 66 residents. Findings include: Review of the medical record for Resident #15 revealed an admission date of 02/16/24 with diagnoses including cerebral infarction, diabetes, and depression. Review of the Minimum Data Set (MDS) assessment for Resident #15 dated 08/06/25 revealed the resident had no cognitive impairments and required substantial assistance to total dependence on staff for activities of daily living (ADLs). […]