Maple Lawn Nursing Home

In the surveyor’s words

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

• Actual harm, isolatedF692Dec 15, 2025

  Based on observation, interview and record review, the facility failed to ensure staff provided adequate nutrition, monitored consumption, monitored or identify weight loss, completed assessments or notified the resident's provider or dietitian of weight loss, and did not evaluate the resident's care plan or initiate interventions to prevent further weight loss for one resident (Resident #14) in a sample of 17 residents. Review of the resident's weight records showed the resident lost 21.8 lbs. since 06/04/25, which was an 11.86 percent (%) weight loss in six months. The resident lost 15.2 lbs. since 10/01/25 (no weight for November documented) which was an 8.5% weight loss in two months. […]

• Actual harm, isolatedF744Dec 15, 2025

  Based on observation, interview and record review the facility staff failed to ensure a resident with dementia (Resident #14), in a review of 17 sampled residents received high-quality, compassionate, and individualized care that supports his/her dignity, well-being, and independence, while addressing the unique challenges posed by dementia. The facility failed to find the root cause and triggers for a resident's behavior and initiate non-pharmacological Interventions, use effective communication strategies, and provide appropriate guidance to staff for managing behavioral symptoms. The resident experienced lethargy, weight loss, physical altercations, agitation, and new skin breakdown. The facility census was 59. […]

• Actual harm, isolatedF600Mar 4, 2025

  Based on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of nine sampled residents, was free from verbal abuse. The resident reported staff (Licensed Practical Nurse (LPN) D) raised his/her voice and told the resident to come on, come on while the resident tried to wheel himself/herself to the bathroom in a wheelchair. Resident #1, who had a diagnosis of aphasia (language disorder that affects a person's ability to communicate effectively), tried to communicate specific needs to LPN D, and when LPN D was not understanding what the resident was trying to say, the resident reached out to touch LPN D's hand so he/she would listen to the resident. LPN D continued to yell at the resident and threaten to call the police. […]

• Actual harm, isolatedF760Feb 20, 2024

  Refer to event id 84PV12 Based on observation, interview and record review, the facility failed to ensure two residents (Resident #1 and #3), received medications as ordered by the physician upon admission to the facility. Resident #1 did not receive medications due to some medications not being available from the pharmacy and because staff failed to accurately transcribe some medications from the resident's hospital discharge orders to the resident's medication administration record (MAR). Apixaban (blood thinner) was omitted from the MAR for 1/31/24 and 2/1/24 through 2/5/24 (10 missed doses). The resident subsequently had a decline which sent him/her to the hospital where he/she was diagnosed with a stroke. […]

• Actual harm, isolatedF760Jan 12, 2024

  Based on observation, interview and record review, the facility failed to ensure two residents (Resident #1 and #3), received medications as ordered by the physician upon admission to the facility. Resident #1 did not receive medications due to some medications not being available from the pharmacy and because staff failed to accurately transcribe some medications from the resident's hospital discharge orders to the resident's medication administration record (MAR). Apixaban (blood thinner) was omitted from the MAR for 1/31/24 and 2/1/24 through 2/5/24 (10 missed doses). The resident subsequently had a decline which sent him/her to the hospital where he/she was diagnosed with a stroke. […]