Maple Lawn Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Maple Lawn Nursing and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF727Jan 30, 2026

  Based on record review and interview, the facility failed to designate an RN to serve as the DON on a full-time basis.The administrator identified 39 residents resided in the facility.Findings:An untitled and undated document showed no designated RN as the DON. On 01/21/26 at 12:27 p.m., during entrance conference the administrator stated the facility had not had a DON for about two weeks.On 01/23/26 at 9:23 a.m., RN #1 stated they had put in their resignation in December 2025 and had stayed on until mid-January 2026. They stated they were tired of being a boss. They stated their last day as DON was 01/16/26.On 01/23/26 at 8:16 a.m., the administrator stated the position was posted on a job website and they had reached out to some RNs currently employed to offer the position to them.

• No harm, potential for more than minimal, patternF641Jan 30, 2026

  Based on observation, record review, and interview, the facility failed to ensure a resident who was not in restraints was not coded for restraints on their MDS assessment for 1 (#18) of 1 sampled resident reviewed for restraints.The MDS coordinator identified six residents had bed rails. Findings:On 01/21/26 at 1:59 p.m., Resident #18 was observed with a quarter bed rail on each side of the head of their bed.An undated Certifying Accuracy of the Resident Assessment policy, read in part, All personnel who complete any portion of the Resident Assessment (MDS) must sign and certify the accuracy of that portion of the assessment.A physician's order, dated 03/27/24, showed Resident #18 could use bed canes (another name for a bed rail]) for repositioning.A care plan, initiated 03/27/24, showed… […]

• No harm, potential for more than minimal, patternF580Apr 21, 2023

  Based on record review and interview, the facility failed to notify or consult with the physician to ensure parameters were identified and followed for FSBS and insulin administration for two (#14 and #17) of four sampled residents reviewed for FSBS. The Resident Census and Conditions of Residents report, dated 04/17/23, documented the census was 39. The DON identified nine residents were insulin dependent. Findings: An undated, Change in a Resident's Condition or Status policy, read in parts, .facility shall promptly notify the .attending physician .of changes in the resident's medical .condition and/or status .nurse will notify the resident's attending physician .when there has been .a need to alter the resident's medical treatment .[when there has been] Instructions to notify the… […]

• No harm, potential for more than minimal, patternF755Apr 21, 2023

  Based on interview and record review, the facility failed to ensure insulin was administered according to the physician order for one (#14) of four sampled residents reviewed for insulin administration. The Resident Census and Conditions of Residents report, dated 04/17/23, documented the census was 39. Findings: A Medication Administration and General Guidelines policy, dated 2019 Edition, read in parts, .Medications are administered as prescribed .in accordance with written orders of the attending physician .contact for clarification prior to the administration . Resident #14 had diagnoses which included type two diabetes mellitus, and edema. AnQuarterly Assessment, dated 01/02/23, documented Resident #14 had severe cognitive impairment, and had received seven days of Insulin. […]

• No harm, potential for more than minimal, isolatedF684Jan 30, 2026

  Based on record review and interview, the facility failed to follow physician's order for obtaining weights for 1 (#1) of 1 sampled resident reviewed for dialysis.The administrator identified one resident resided received dialysis. Findings: An undated Weights policy, read in part, The nursing staff will measure resident weights on admission. If no weight concerns are noted at this point, weights will be measured monthly thereafter or according to the doctors orders.An undated Face sheet showed Resident #1 had diagnosis which included stage 3 chronic kidney disease.A physician's order, dated 10/14/21, showed Resident #1 was to be weighed daily, and notify primary care physician if greater than three pounds weight gain in 24 hours.A Weight Variance Report, dated 07/01/25 through 01/31/26,… […]