Maple Manor Care Center

In the surveyor’s words

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

• Actual harm, isolatedF697Sep 10, 2025

  Based on observation, record review, review of professional reference, and resident and staff interview, the facility failed to develop and provide an effective pain management regimen to meet resident needs for 2 of 14 sampled residents (Resident #4 and #5) reviewed for pain management. Failure to develop, implement, and provide an effective pain management plan resulted in unresolved pain and discomfort and decreased quality of life. Findings include:Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, pages 625-626, stated, . pain is a physical and emotional experience . Pain interferes with functional abilities and quality of life. […]

• Actual harm, isolatedF678Nov 15, 2022

  Based on record review, review of the facility reported incident investigation, review of facility policies, review of personnel records, and staff interview, the facility failed to perform Cardiopulmonary Resuscitation (CPR) on 1 of 1 resident (Resident #1) who requested CPR in the event of absence of pulse or respirations. Failure to perform CPR contributed to Resident #1's death. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: Review of the facility policy titled Emergency Procedure-Cardiopulmonary Resuscitation occurred on [DATE]. This policy, revised [DATE], stated, . […]

• No harm, potential for more than minimal, widespreadF801Sep 10, 2025

  Based on review of a facility job description and staff interview, the facility failed to ensure 1 of 1 dietary manager (#11) obtained the proper qualifications to serve as the dietary manager. Failure to ensure staff have the qualifications to carry out the functions of a manager in the dietary department has the potential to result in foodborne illness to residents, staff, and visitors.Findings include: Review of the facility job description titled Dietary Manager occurred on 09/10/25. This undated job description stated, . Minimum requirements include one of the following . Certification as a dietary manager . Certification as a food service manager . Has similar national certification for food service management and safety from a national certifying body . […]

• No harm, potential for more than minimal, widespreadF868Sep 10, 2025

  Based on review of the facility Quality Assurance and Performance Improvement (QAPI) program, review of the facility policy, and staff interview, the facility failed to ensure the Medical Director (physician) actively participated on the Quality Assurance (QA) committee for 3 of 4 quarters (July-September 2024, October-December 2024, and April-June 2025). Failure to ensure the medical director participates in the facility's QA activities deprived the committee of the physician's unique contribution for analyzing and correcting problems with identified resident care areas.Findings include: Review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) Program - Governance and Leadership occurred on 09/10/25. This policy, revised January 2025, stated, . […]

• No harm, potential for more than minimal, widespreadF881May 12, 2022

  Based on review of facility guideline/pre-antibiotic checklist and staff interview, the facility failed to consistently implement ongoing review for an antibiotic stewardship program. Failure to implement a system of antibiotic monitoring to ensure the correct indication, dose, and duration may result in adverse outcomes, the unnecessary use of antibiotics, and the development of antibiotic-resistant organisms. Findings include: Review of the facility guideline/pre-antibiotic checklist titled Agency for Healthcare Research and Quality: Four Moments of Antibiotic Decision Making Form occurred on 05/12/22. This guideline, dated June 2021, stated, . form is to help team incorporate the four moments of antibiotic decision making into daily practice in your facility . […]