The Greens at Maple Leaf

In the surveyor’s words

From the most serious findings on record at The Greens at Maple Leaf, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 22, 2025

  Based on observations, record reviews and interviews with staff, Nurse Practitioner (NP) and Medical Director, the facility failed to provide care in a safe manner when Resident #1 rolled out of her bed and hit the floor during incontinence care. Resident #1 was sent to the Emergency Department (ED) and diagnosed with an occult (subtle hip bone break often in older adults that often does not show up on imagining but causes pain, tenderness, and difficulty walking) nondisplaced (the bone breaks but maintains it proper alignment) left hip fracture, distal left femur fracture (fracture of the lower portion of the thighbone near the knee joint) and a left side scalp hematoma (bruise that occurs when blood pools outside blood vessels). […]

• Actual harm, isolatedF600May 15, 2024

  Based on observations, record review, resident, staff, and Nurse Practitioner interviews the facility failed to protect a resident's right to be free from abuse when Resident #17 asked Nurse Aide (NA) #1 multiple times to let go of his right arm during incontinent care and when she did not Resident #17 pulled his right arm away from NA #1 and during the interaction received a small skin tear with a red/purple bruise that was approximately the size of a half dollar on his right forearm for 1 of 3 residents reviewed for accidents. Resident #17 stated that NA #1 ignored his request to let go of his arm and then laughed at him. The skin tear required a treatment with calcium alginate (dressing used for management of draining wounds) three times weekly and as needed. […]

• Actual harm, isolatedF600Mar 1, 2023

  Based on record review and staff interviews the facility failed to provide supervision to prevent a cognitively impaired resident (Resident #129) from attacking another cognitively impaired resident (Resident #130) in their shared bathroom which result in Resident #130 having a bloody right lower lip, left nare and left cheek. Her right wrist was swollen, bruised, and painful and required evaluation at the emergency room (ER). The Findings included: Resident #129 was admitted to the facility on [DATE] and expired in the facility on [DATE]. Resident #129's diagnoses included schizoaffective disorder, dementia, and bipolar disorder. […]

• No harm, potential for more than minimal, patternF812Jul 31, 2026

  Based on observation and staff interviews, the facility failed to maintain sanitary conditions in 1 of 1 walk-in cooler, 1 of 1 walk-in freezer, and 1 of 1 dry storage area. These practices had the potential to affect food served to residents. The findings Included:a. During the initial tour of the kitchen with the Dietary Manager on 07/28/2026 at 10:50AM, the following was observed in the walk in cooler:-Six (6) single serve ice cream cups observed on the floor underneath the shelving unit,-Several pieces of used plastic cling wrap observed underneath the shelving unit,-Other unidentified debris was scattered throughout the walk-in cooler floor and underneath the shelving unit,-A dark brownish/ grayish/ blackish substance was observed scattered across an extended area of the left wall of… […]

• No harm, potential for more than minimal, patternF761Jul 3, 2025

  Based on manufacturer guidelines, observations and staff interviews, the facility failed to remove loose and unsecured pills of various shapes, sizes and colors from 2 of 6 medication carts (100 and 200 Hall) and failed to label DuoNeb solution (inhalation breathing solution) with a open date and store DuoNeb solution according to the manufacturer's guidelines for 1 of 6 medication carts (200 Hall) reviewed for medication storage. The findings included: 1a. An observation was made of the 100 hall medication cart on 07/02/25 at 10:45 AM accompanied by Medication Aide (MA) #1. The cart yielded 20 loose pills of various shapes, colors and sizes in the bottom of the medication cart drawers. An interview conducted with MA #1 on 07/02/25 at 10:45 AM. […]