Maple Lawn Senior Care

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF727Feb 26, 2026

  Based on interview and record review, the facility failed to ensure a registered nurse (RN) was on duty a minimum of 8 consecutive hours per day, 7 days a week for 1 of 92 days reviewed. This had the potential to affect all 33 residents. Findings include: Review of the facilities November 2025, December 2025, and January 2026 schedules identified on 11/29/25 the facility had no registered nurse on duty. Interview on 2/26/26 at 8:23 a.m., with the director of nursing identified she was responsible for the licensed nurse schedule. She reported she was on duty Monday through Friday 8 consecutive hours and if she needed to leave early, she would ensure there was another RN to cover the 8-hour requirement. […]

• No harm, potential for more than minimal, widespreadF801Feb 26, 2026

  Based on observation, interview, and document review, the facility failed to designate a qualified person to serve as the director of food service to oversee the dietary department. This had the potential to affect all 33 residents.Findings include: Interview on 2/23/26 at 12:00 p.m., with the facility designated dietary manager (DM) revealed she was not certified. She had been enrolled but dropped the class this past December because of personal life issues that made it difficult for her to continue. She had not submitted any of her course work that was required to complete the class and currently was not enrolled in any program. […]

• No harm, potential for more than minimal, widespreadF812Dec 18, 2024

  Based on observation, interview, and document review the facility failed to discard food that had expired, ensure all foods were labeled and dated, and maintain a clean fan that blew in the direction of clean dishes. This had the potential to affect all 37 residents residing in the facility. Findings include: Observation and interview on [DATE] at 10:44 a.m., with the dietary manager (DM) during initial tour of the kitchen. An observation of the refrigerator next to the food prep area contained 2 half gallons of milk with best use by date of [DATE]. The DM stated the milk should have been tossed out on [DATE]. The walk-in cooler contained 4 dishes of dessert that was not labeled or dated and a pre-made salad in a bowl that was dated [DATE] and was brown in color. […]

• No harm, potential for more than minimal, widespreadF867Feb 14, 2024

  Based on interview and document review, the facility failed to ensure data submitted to the QAPI committee was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 41 residents. Findings include: Review of quarterly QAPI meetings from January 2023 through December 2023, identified the facility departments were submitting data to be reviewed by the committee. 2 Examples of failure to analyze and document that process identified in: 1. Quarter 2 April, may, and June of 2023, identified data brought forth that included pressure ulcers, falls, catheter use, and infections. […]

• No harm, potential for more than minimal, patternF755Dec 18, 2024

  Based on observation, interview and document review the facility failed to ensure 1 of 2 narcotic emergency kit (E-kit) containing controlled and/or narcotic substances did not have expired medications, and ensure the E-kit contents label was updated monthly and current. Findings include: Observation on 12/16/24 at 5:40 p.m., with contract registered nurse RN-(A) of the medication room, identified a large narcotic E-kit, with a red numbered tag of 882350. RN-A stated the red tag indicated the E-kit had not been opened. […]