Maple Lawn Medical Care Facility

In the surveyor’s words

From the most serious findings on record at Maple Lawn Medical Care Facility, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 27, 2025

  Based on observation, interview, and record review the facility failed to implement interventions to prevent accidents for two residents (#2, #6) of three resident reviewed for accidents resulting in major injury (fracture and brain bleed) and hospitalization for resident #2.Findings Included: Resident #2 Review of the medical record demonstrated R2 was admitted [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), dementia, repeated falls, constipation, psychotic disorder with delusion, hypothyroidism (low thyroid hormone), vitamin D deficiency, chronic kidney disease, depression, gastro-esophageal reflux, osteoarthritis (arthritis that occurs when flexible tissue at the end of bones wears down), chronic pain, hyperlipidemia (high fat content in blood). […]

• Actual harm, isolatedF689May 26, 2022

  Based on interview and record review, the facility failed to provide adequate supervision and implement appropriate care planned interventions to prevent falls for 2 of 7 residents (Resident #7 and #56) reviewed for falls, resulting in falls with injuries and fractures negatively affecting the residents highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #7: Review of an Admission Record revealed Resident #7 was a male with pertinent diagnoses which included laceration of scalp, traumatic subarachnoid hemorrhage with loss of consciousness (acute [CONDITION(S)] with bleeding in the brain), history of urinary infections, suprapubic catheter (inserted into a hole in abdomen then directly into the bladder), history of falling, and chronic pain. […]

• No harm, potential for more than minimal, widespreadF880Aug 15, 2024

  Based on interview and record review the facility failed to provide appropriate infection surveillance for all residents (100 current residents) and take appropriate actions to track, trend, and formulate corrective actions to decrease the spread of nosocomial infections in the facility. Findings Included: During an interview on 08/15/2025 at 09:32 a.m. Infection Control Preventionist (ICP) C explained that he had been in his current position since February of 2024 and was responsible for the data collection and review of information regarding infections in the facility. ICP C explained that he reviewed the data and would identify trends that potentially required interventions to prevent further spread of infection. […]

• No harm, potential for more than minimal, widespreadF812May 26, 2022

  Based on observation, interview, and record review the facility failed to 1. properly store, date, and discard food items; and 2. address temperatures out-of-range for refrigeration units and dish machine. These conditions resulted in an increased risk of food borne illness that affected 82 of 83 residents who consume food from the kitchen. Findings include: Review of a facility policy, Food Storage: Labeling/Dating Food Items, dated 5/22, revealed, . Policy Interpretation and Implementation . a. Packaged items shall be dated upon opening with current date. b. All open, dated items will be disposed of on the fifth day following the open date or by the manufacturer's suggested use by date. c. All unopened items will be disposed of according to the manufacturer's use by date. d. […]

• No harm, potential for more than minimal, widespreadF886Sep 30, 2021

  Based on interview and record review, the facility failed to conduct timely COVID-19 testing for two residents (Resident #3 and Resident #4) of two residents and failed to demonstrate that COVID-19 testing was offered, completed, and results of each test were documented in the medical record for eight residents (Resident #1, #2, #3, #4, #5, #6, #7 and #8) of eight reviewed resulting in a delay in treatment, exposure to others in the facility, and lack of access to results for all medical providers involved in the resident's care. Findings include: Resident #3 (R3) Review of the medical record revealed that Resident #3 (R3) was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3 was discharged from the facility on 09/14/21. […]