Average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Maple Crest Manor during CMS and state inspections, most recent first.
Dietary staff failed to prepare correct puree portions and did not serve the approved pureed menu for several residents. Staff blended meat, broccoli, and dessert items with added liquid, then portioned them with the same scoop size without measuring the final volume, and also failed to puree pasta Alfredo and provide garlic bread. The DON/designee confirmed the expected use of the puree portion chart, but the meal was served without the approved items.
Food storage, sanitation, hand hygiene, and hair restraint failures were observed in the kitchen. Multiple opened food and beverage items were left undated or improperly stored, equipment such as the microwave, griddle, oven, toaster, steam table, and ice machine had heavy soil buildup, and staff were observed handling food with soiled gloves, failing to wash hands between tasks, and touching ready-to-serve food and utensils with bare or contaminated hands. Staff and therapy personnel also entered the kitchen without hairnets, and cold beverages were held above the posted temperature range.
A resident with dementia, depression, severe cognitive impairment, and frequent aggressive behaviors was involved in a care interaction where a CNA used a stern and yelling tone while the resident was hitting and pinching staff during toileting and a 2-person transfer. Other staff heard the CNA yell phrases such as stop, quit, and knock it off, and one CNA said the tone was inappropriate and more than just loud. The resident’s care plan called for calm redirection and a supportive approach, and the facility’s resident rights policy required dignity and respect.
Inaccurate MDS coding affected two residents. One resident with dementia was coded as receiving an antipsychotic even though the EMAR showed Donepezil, not an antipsychotic, and the ADON/MDS Coordinator said she believed dementia drugs were classified as antipsychotics. Another resident was also coded for antipsychotic use without EMAR support, and the quarterly MDS failed to document oxygen use despite an active oxygen order and ETAR documentation showing it was provided.
Failure to Maintain Oxygen Tubing and Concentrator Filter: A resident receiving oxygen for comfort was observed multiple times with undated oxygen tubing and a visibly dirty concentrator external filter. EMAR/ETAR review lacked documentation that staff changed the tubing or cleaned the filter, and staff interviews showed uncertainty about documentation and responsibility for oxygen equipment care despite facility policy and the manufacturer manual requiring routine tubing changes and weekly filter cleaning.
Failure to Provide Ordered Divided Plates: Two residents with Parkinson’s disease were supposed to receive meals on divided plates, as shown on their meal tickets and dietary lists, but dietary staff served both meals on regular plates instead. One resident reported losing food onto the floor when eating without the divided plate, and staff stated the adaptive equipment was listed on the meal ticket and a cheat sheet above the steam table.
A resident receiving hospice care for terminal CVA and HF was affected by a hospice contract that did not include required language for immediate notification to the hospice administrator if the facility became aware of alleged abuse, mistreatment, neglect, or misappropriation by hospice staff. The existing contract addressed incident reporting generally, but it did not specify the required immediate reporting process, and the Administrator confirmed the contract had not been updated.
A resident with hypertension, renal insufficiency, and diabetes mellitus who received dialysis three times weekly did not have required pre- and post-dialysis assessments completed on multiple occasions, despite care plan directives. The ADON confirmed the expected assessments were missing from the clinical record.
A resident with an indwelling urinary catheter did not receive care in accordance with enhanced barrier precautions, as a CNA failed to wear a gown during high-contact catheter care despite facility policy and posted signage requiring both gloves and gowns. The care plan also lacked directives for EBP, and the issue was confirmed by the ADON/IP.
Incorrect Pureed Meal Preparation and Menu Service
Penalty
Summary
The facility failed to prepare correct pureed servings and failed to serve the dietician-approved pureed menu for 4 of 4 residents reviewed. On the lunch menu, the pureed meal was to include lemon garlic pork loin, pasta Alfredo, broccoli, garlic toast, and pumpkin earthquake cake. During observation, dietary staff prepared the pork loin by blending 16 oz with gravy and then used a 4 oz scoop to portion four servings, leaving more than 1/2 cup of mixture in the blender. The broccoli was prepared in a similar manner, with staff blending four 4 oz servings, adding milk, and then using the same 4 oz scoop to portion four servings, leaving about 1/2 cup in the blender. For the pumpkin earthquake cake, staff blended five cake squares with milk, added more milk several times, and then used a 4 oz spoodle to portion four servings, leaving about one cup of mixture in the blender. Staff failed to measure the total volume of the pureed mixtures and did not use the Pureed Diet Portion Sizes/Dishers Chart after additional liquid was added during preparation. Staff also failed to puree the pasta Alfredo and the garlic bread. The dietary supervisor stated the staff were expected to measure the total volume of the puree mixture and use the chart to determine the correct serving size, and also acknowledged that the pasta Alfredo had not been prepared or substituted and that the garlic bread had not been provided. At the meal observation, three residents had eaten almost all of the pureed food and staff were still assisting the fourth resident with the meal.
Food Storage, Sanitation, Hand Hygiene, and Hair Restraint Failures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards. During kitchen observations, multiple opened food and beverage items were found undated, including thickened juices, thickened water, chocolate milk, white milk, sour cream, chicken base, butter, and frozen items in torn or unsecured packaging. Staff were observed placing date tape on some beverage bottles only after they were already in storage, despite labels directing that opened products be discarded within a specified number of days. The freezer and refrigerator also contained several opened or exposed items that were not sealed or dated. Food contact and non-food contact equipment were observed with heavy accumulations of soil and residue. The microwave had orange, greasy splatter on the top, back, and sides. The griddle, oven, toaster, steam table wells, and the top of the ice machine all had black, brown, or gritty tacky buildup, and the steam table had food spills extending below the shelf and around the burner dials. The report also noted that the steam table and other equipment were documented as cleaned on the facility’s cleaning audit, yet the observed soil remained present during repeated visits. Staff practices during food preparation and service showed repeated failures with hand hygiene, glove use, and food handling. Staff were observed handling breaded shrimp and other foods with gloved hands after touching other surfaces, placing dirty utensils into the dishwasher and then returning to food service without washing hands, and using a bare hand to touch a food processor blade before preparing food for a resident. A dietary supervisor also prepared a sandwich while wearing gloves that contacted multiple surfaces and the finished sandwich was served to a resident. In addition, staff and therapy personnel entered the kitchen without hairnets, and cold beverages were held in a container without ice and measured at 44.5 degrees Fahrenheit, above the posted temperature range.
Failure to Treat Resident with Dignity During Care Interaction
Penalty
Summary
The facility failed to ensure a staff member treated a resident with dignity and respect during an interaction involving Resident #27 and Staff O, CNA. Resident #27 had short- and long-term memory problems, severely impaired cognitive skills for daily decision-making, dementia, depression, physical and verbal behavioral symptoms toward others, dependence on staff for hygiene, bathing, dressing, transfers, and frequent urinary and bowel incontinence. The resident also received hospice care and had care plan interventions for two-person transfers, calm redirection, and approaches intended to reduce agitation. On the morning of the incident, Staff O and another CNA entered the resident’s room to assist with toileting and a two-person transfer. Staff O stated the resident began hitting and pinching her when staff attempted to stand her from the toilet, and she responded by using a stern voice and telling the resident it hurt and to stop. Other staff reported hearing Staff O yell at the resident, including telling her to stop, quit, knock it off, and that she was being rude. One CNA stated the tone of voice was inappropriate and more than just loud, and another stated the yelling caused concern. Staff and management accounts described the resident as having frequent aggressive behaviors, including hitting, pinching, scratching, biting, kicking, spitting, and grabbing staff, especially during morning care and when awakened. Staff also stated the resident’s behaviors varied by day and that she could be difficult to get up. The facility’s resident rights policy required residents to be treated with respect and dignity and cared for in a manner and environment that promotes quality of life and recognizes individuality.
Inaccurate MDS Coding for Antipsychotic Use and Oxygen
Penalty
Summary
The facility failed to ensure nursing staff accurately completed MDS assessments for 2 of 15 residents reviewed. For one resident with Alzheimer’s disease, the quarterly MDS documented that the resident received an antipsychotic medication during the 7-day lookback period, but the May 2026 EMAR did not show any antipsychotic administration. The clinical order list instead showed Donepezil 5 mg daily, and the ADON/MDS Coordinator stated she coded the resident as receiving an antipsychotic because she believed medications used to treat dementia, such as Donepezil and Memantine, were classified as antipsychotics. For another resident with non-Alzheimer’s dementia, the significant change MDS documented antipsychotic use during the 7-day lookback period, but the May 2026 EMAR did not document antipsychotic administration and instead showed Donepezil 10 mg at bedtime, with all doses signed out as administered. The same resident’s quarterly MDS also documented respiratory failure and shortness of breath when lying flat, but did not document oxygen use even though the ETAR showed an order for oxygen 2-5 liters per nasal cannula for comfort every shift and nursing staff signed it out as provided during the lookback period. The ADON/MDS Coordinator stated she used progress notes, staff input, and an MDS worksheet, and later acknowledged the oxygen entry was a miscode and needed to be modified.
Failure to Maintain Oxygen Tubing and Concentrator Filter
Penalty
Summary
Safe and appropriate respiratory care was not provided for a resident receiving oxygen therapy when the facility failed to change and date the oxygen tubing and failed to maintain a clean exterior filter on the oxygen concentrator. Resident #7 had a BIMS score of 14 out of 15, indicating intact cognition, and the MDS documented shortness of breath when lying flat and a diagnosis of respiratory failure. A physician order dated 5/29/26 directed oxygen via nasal cannula at 2-5 liters for comfort, and the resident was observed using oxygen at 2 liters per nasal cannula in the dining room and later in bed with oxygen running continuously from a concentrator. During repeated observations, the oxygen tubing remained undated and the concentrator external filter was noted to have a white, gritty film. The condition of the tubing and filter was unchanged across multiple observations, and review of the June and July 2026 EMAR and ETAR lacked documentation that staff changed the tubing or cleaned the external filter. Staff interviews reflected uncertainty about where tubing changes were documented, while the DON stated tubing was changed every 14 days and the ADON stated the oxygen supplier addressed filter cleaning; the ADON later confirmed the concentrator was a facility-owned unit and the external filter was dirty and needed to be cleaned. The facility policy required oxygen tubing to be changed every 14 days and the manufacturer manual directed weekly washing of the air intake gross filter.
Failure to Provide Ordered Divided Plates
Penalty
Summary
The facility failed to provide divided plates for 2 of 7 sampled residents who were identified as needing adaptive eating equipment. The facility’s diet order spreadsheet, updated July 7, listed seven residents who required divided plates, including two residents with Parkinson’s disease. One resident’s nutritional problem care plan, dated February 24, did not include direction to provide a divided plate, while the other resident’s care plan included an occupational therapy recommendation from April 14 to provide a divided plate for meals. During meal observation, dietary staff plated both residents’ lunches on regular plates instead of divided plates even though each resident’s meal ticket listed divided plate use under adaptive equipment. One resident was served broccoli, breaded shrimp, and cocktail sauce on a regular plate, and the other was served breaded shrimp, French fries, and garlic bread on a regular plate. One resident reported she usually received meals on a divided plate and lost food onto the floor when trying to eat lunch without it, while the other resident and a family member stated the resident was supposed to receive meals on a divided plate. Dietary staff stated the adaptive equipment was listed on the meal ticket and on a cheat sheet above the steam table, and staff should check both sources when serving meals.
Hospice Contract Missing Required Abuse Reporting Language
Penalty
Summary
The facility failed to ensure its written hospice agreement included required language requiring immediate notification to the hospice administrator when the facility becomes aware of alleged abuse, mistreatment, neglect, or misappropriation of resident property by hospice staff. Resident #16 was receiving hospice services for terminal CVA (stroke) and heart failure, with Hospice A identified as the provider in the care plan dated 7/5/2026. Review of the facility’s hospice contract with Hospice A, dated 9/23/2015, showed incident reporting language for alleged mistreatment, neglect, verbal, mental, sexual or physical abuse, injuries of unknown source, or misappropriation of patient property, but it did not specify that facility staff must report alleged incidents involving hospice staff to the hospice administrator immediately when the facility becomes aware. During interview, the Administrator stated the facility did not have an updated hospice contract containing the missing required language.
Failure to Complete Pre- and Post-Dialysis Assessments
Penalty
Summary
The facility failed to complete required pre- and post-dialysis assessments for a resident with diagnoses of hypertension, renal insufficiency, and diabetes mellitus who received dialysis three times a week. The resident's care plan specified that nurses were to document and monitor complications, pre- and post-dialysis weights, and access sites, and to complete pre- and post-dialysis assessments on each dialysis day. Clinical record review revealed multiple instances where pre-dialysis assessments were not completed on specified dates, as well as numerous dates where post-dialysis assessments were missing. The Assistant Director of Nursing confirmed that these assessments were expected but not documented as required.
Failure to Implement Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
A deficiency was identified when staff failed to utilize enhanced barrier precautions (EBP) during high-contact care for a resident with an indwelling urinary catheter. The resident, who had diagnoses including hypertension, coronary artery disease, depression, and severe cognitive impairment, required an indwelling catheter due to hydronephrosis with ureteropelvic junction obstruction. The care plan for this resident did not include directives for EBP, despite the presence of a catheter. Facility signage and policy required the use of gloves and gowns for high-contact activities involving indwelling devices, in accordance with CDC guidance. During observation, a CNA entered the resident's room to empty the urinary catheter bag, performed hand hygiene, and wore gloves, but failed to don a gown as required by EBP protocols. The CNA later acknowledged forgetting to use the gown. The Assistant Director of Nursing/Infection Preventionist confirmed that EBP should be used for residents with catheters and that the care plan should reflect this requirement. The facility's policy also directed the use of gowns and gloves for such care, but this was not followed in practice for the resident in question.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fayette
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan - West Union | 9 mi | ★★★★★ | 11 | 0 |
| Grandview Healthcare Center | 12.7 mi | ★★★★★ | 5 | 0 |
| Oelwein Health Care Center | 12.8 mi | ★★★★★ | 9 | 0 |
| Hillcrest Home | 15.3 mi | ★★★★★ | 12 | 0 |
| Strawberry Point Lutheran Home | 17.5 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.