Maple Woods Manor

In the surveyor’s words

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

• Actual harm, isolatedF600Apr 8, 2026

  This citation pertains to Intake Numbers 2685912 and 2701537.Based on interview and record review the facility failed to protect one resident's (Resident #302) right to be free from neglect, resulting in 1. Significant delay in the administration of enteral nutrition and hydration; 2. Discharge medication orders (insulin and tube feed formula) were not followed without a rationale; 3. Untimely intervention for persistently elevated blood glucose levels and lack of communication to the practitioner; and 4. An ongoing respiratory assessment and monitoring of an acute infection with antibiotic administration, which led to an unnoticed change in condition requiring hospitalization. […]

• Actual harm, isolatedF684Jun 24, 2025

  This citation pertains to Intake Numbers MI00153484 and MI00153865. Based on interview and record review the facility failed to promptly assess a change in condition for one resident (Resident #501) of two residents reviewed for pain, resulting in a delay in pain treatment and discovery of bilateral femur fractures. Findings include: Resident #501: On 6/20/2025 at 9:45 AM, Resident #501 was observed sleeping in bed and did not appear to be in any distress. Two CNA (Certified Nursing Assistants) in the room shared the resident is a two person assist and fully dependent on care. On 6/20/2025 at 10:42 AM, Maintenance Director O shared the Shower Aide informed her as they were lowering Resident #501 in the bed (via mechanical lift) it tilted forward. […]

• Actual harm, isolatedF686Jan 21, 2025

  This citation pertains to Intake Number MI00149458. Based on observation, interview and record review, the facility failed to operationalize policies and procedures for skin/wound assessments and prevent the development of pressure ulcers for three residents (Resident #1, Resident #2, and Resident #3) of three residents reviewed for wound and skin care, resulting in Resident #1's development of facility- acquired Stage III pressure ulcer to the coccyx area, five suspected deep tissue injuries on the right and left feet and pain; Resident #2's development of facility-acquired right buttock pressure wound stage II and right ischium pressure wound stage IV, and the potential for wounds to go undetected and untreated, pain and wound infection. […]

• Actual harm, isolatedF692Feb 15, 2024

  Based on observation, interview and record review, the facility failed to ensure an ongoing and comprehensive nutritional assessment and timely implementation and evaluation of person-centered interventions to prevent weight loss for one resident (Resident #94) of two residents reviewed, resulting in Resident #94 experiencing a severe weight loss and the likelihood for a decline in overall health status. Findings include: An observation of Resident #94 occurred on 2/12/24 at 11:53 AM in their room. The room was dark, with the light with the overhead lights off and the window shades closed. The Resident was in bed, with one leg half off the bed and their eyes open. The Resident had a gaunt appearance. […]

• Actual harm, isolatedF690Nov 3, 2022

  Based on observation, interview, and record review, the facility failed to 1.) assess and monitor for urinary/catheter changes for Resident #33 and prevent facility acquired urinary tract infections for three (3) Residents (#9, #76, #95) resulting in the likelihood for bladder injury, cross contamination and facility acquired urinary tract infections requiring antibiotic therapies. Findings Include: Record review of facility 'Urinary Tract Infection; Catheter Associated UTI's (CAUTI's) Prevention & Surveillance Guidelines' policy dated 10/2011 revealed it is the policy of the facility to apply evidenced-based guidelines to alterable risk factors in the development of nosocomial Urinary Tract Infections (UTI's) . […]