Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Maple Heights during CMS and state inspections, most recent first.
Controlled substances were not stored under double lock for several residents. During a med pass observation, staff said scheduled Ativan and Clonazepam were kept with other meds and were not tracked with narcotic sheets, while PRN doses were counted and documented. Record review showed cassettes of Ativan and Clonazepam for multiple residents were in the med cart without double lock, and the DON stated the facility did not have a policy on controlled substance storage.
The facility failed to follow infection control practices during wound care and catheter-related care. An LPN did not perform hand hygiene at the appropriate time and did not wear a gown during wound treatment for a resident with a heel wound, and a CNA applied catheter extension tubing for another resident without a gown despite EBP orders. The facility also failed to regularly document weekly hot water temperatures for legionella monitoring, with records missing for an extended period.
Failure to monitor and document response to psychotropic medication changes: A resident with cognitive impairment and high-risk psychotropic use had multiple antidepressant and antianxiety medication changes, but the chart lacked nursing notes during key periods, lacked documentation of response to the changes, and lacked vital sign assessments including HR, RR, and temperature. The resident reported vivid dreams, nightmares, and not feeling well, later developed SOB, was sent to the hospital, and was found to have a PE. Staff and the DON stated there was no specific required monitoring form and that changes were not necessarily documented.
The facility failed to complete required quarterly smoking safety evaluations for two residents who smoked and had intact cognition. One resident had diagnoses including HF, PVD, COPD, and nicotine dependence, and the other had CAD, HF, DM, and COPD. The DON confirmed the last smoking assessments were not current for either resident and that the facility expected quarterly evaluations.
A facility failed to develop a comprehensive care plan for a resident with an indwelling catheter, omitting Enhanced Barrier Precautions. The resident's care plan lacked necessary directives despite a physician's order for monthly catheter changes. The DON acknowledged the absence of a policy on care plan accuracy, relying on professional standards and the RAI.
A medication cart was left unlocked and unattended for five minutes by an LPN, during which a resident in a wheelchair passed by. An RN later locked the cart. Interviews with staff confirmed that medication carts should be locked when not in use or out of the nurse's eyesight, although the facility lacks a specific policy for this practice.
The facility failed to implement Enhanced Barrier Precautions for three residents requiring special care, including enteral feeding and catheter use. Staff did not wear gowns as required, despite the facility's policy mandating PPE for residents with indwelling medical devices. Observations and interviews confirmed the deficiency in infection prevention and control practices.
The facility failed to replace food items before their recommended past due date. A bin of flour in the kitchen was found with a date indicating it was last filled several months ago. The CDM was unsure of the flour's shelf life, but the dietician confirmed it should not exceed six months. The facility's policy required food rotation, which was not followed.
A facility failed to provide a comprehensive care plan for a resident, lacking goals and interventions for pain management with opioids. The resident, with no cognitive impairment and a diagnosis of pain, had a physician's order for Tramadol. The care plan did not include necessary elements for managing pain, and the DON acknowledged this absence, noting the facility follows CMS RAI guidelines.
A resident with severe cognitive impairment and multiple diagnoses, including heart failure and dementia, tested positive for COVID-19. Despite being treated with an antibiotic and steroid, the care plan was not updated to include specific interventions or monitoring goals. The facility lacked a specific policy for care plan updates, relying on general standards of care.
A resident with an indwelling catheter was observed with their catheter bag improperly secured to a trash can, lacking a dignity cover. A CNA confirmed the practice, and the DON stated the facility's expectation was for the catheter to be placed on a barrier on the ground, although no specific policy existed.
Controlled substances not double locked
Penalty
Summary
The facility failed to ensure that controlled substances were stored under double lock for 4 of 46 residents reviewed. During a medication pass observation on 12/16/2025 at 8:06 AM, several residents had controlled drugs, including Ativan and Clonazepam, stored in the medication drawer with the rest of the scheduled medications. An LPN stated that scheduled doses of Ativan and Clonazepam were kept with the other medications and that there were no narcotic sheets to monitor the daily count. Later that day, an RN stated that narcotic sheets were kept only for PRN doses, not for scheduled Ativan or Clonazepam. Record review showed that Resident #49, who had diagnoses including renal insufficiency, anxiety disorder, depression, and psychotic disorder, had an order for clonazepam 1 mg daily for insomnia, and the medication cart contained a cassette of clonazepam tablets that was not double locked. Resident #45, with diagnoses including diabetes mellitus, Alzheimer's Disease, anxiety disorder, and depression, had orders for Ativan 0.5 mg in the morning and afternoon and clonazepam 0.5 mg twice daily, and the medication cart contained cassettes of Ativan and clonazepam that were not double locked. Resident #7 had an order for Ativan 1 mg twice daily, and the medication cart contained a cassette of Ativan that was not double locked. Resident #11, who had Alzheimer's Disease, anxiety disorder, and depression, had an order for Ativan 0.5 mg daily, and the medication cart contained a cassette of Ativan that was not under double lock. The DON stated that the facility was counting, double locking, and double documenting PRN controlled substances but not scheduled Ativan or Clonazepam, and said the pharmacy sent a 14-day supply of scheduled doses. The DON also stated that the facility did not have a policy on storage of controlled substances.
Infection Control and Water Monitoring Failures
Penalty
Summary
The facility failed to use universal infection control measures and Enhanced Barrier Precautions during resident care. Resident #20 had diagnoses including heart failure, renal insufficiency, diabetes mellitus, and a stage 2 pressure ulcer, and had a physician order for treatment to the left heel. During observation, an LPN removed the old dressing with gloves and completed hand hygiene, but then did not perform hand hygiene before putting on new gloves to continue the wound treatment. The LPN also did not don a gown during the dressing change. In interview, the LPN stated she should have worn a gown for the dressing change and should have completed hand hygiene after removing the old dressing and before putting on new gloves. The facility also failed to use Enhanced Barrier Precautions during catheter-related care for Resident #5, who had a BIMS score of 15, was independent with eating, hygiene, dressing, and transferring, and had an indwelling urinary catheter related to urinary retention. His care plan directed staff to assist with catheter care and use EBP, including gown and gloves. During observation, a CNA assisted with applying catheter extension tubing while wearing gloves but without a gown. In addition, the facility failed to monitor for legionella growth because weekly hot water temperatures were not documented regularly since April 2024. Staff and the Administrator acknowledged the lack of documentation, and the facility policy stated that records are kept to protect the integrity of the water.
Failure to Monitor and Document Response to Psychotropic Medication Changes
Penalty
Summary
The facility failed to provide increased monitoring and assessment after multiple psychotropic medication changes for Resident #7, who had a BIMS score of 10, impaired cognitive function, impaired thought process, and was receiving high-risk drugs including an antipsychotic, antianxiety medication, and an antidepressant. Her care plan directed staff to administer medications as ordered and monitor for side effects and effectiveness, including observing for adverse reactions such as increased irritability, lethargy, blurred vision, and nausea/vomiting. On 7/22/25, the resident had new orders to taper and stop Lexapro and Ativan, start mirtazapine for anxiety, reduce midodrine, and monitor blood pressure twice daily for 3 weeks. The chart lacked nursing progress notes from 7/23 through 7/26, and after the resident reported vivid dreams and uncertainty about taking nighttime pills on 7/26/25, the chart again lacked nursing notes from 7/26 through 7/29. On 7/29/25, after the resident's daughter reported nightmares and that the resident was not feeling well, the facility discontinued mirtazapine and started buspirone, and later discontinued melatonin. From 7/29/25 through 8/6/25, the progress notes lacked documentation of the resident's response to the medication changes, and the vitals tab lacked heart rate, respiratory assessment, or temperature documentation. The resident later reported shortness of breath and not feeling well all day and was transferred to the hospital, where she was found to have a pulmonary embolism. Staff and the DON stated they did not have a specific form or required documentation for extra monitoring when a resident had a medication change, and the DON said the resident had been on their radar but the nurses did not necessarily document it.
Failure to Complete Required Smoking Safety Assessments
Penalty
Summary
The facility failed to assess two residents for safety while smoking. Resident #13 had an MDS BIMS score of 15, indicating intact cognition, and diagnoses of heart failure, peripheral vascular disease, COPD, and nicotine dependence. The resident stated during interview that she smokes at the facility and reported no issues while smoking there. A facility document titled Safe Smoking Evaluation showed the last smoking safety evaluation for Resident #13 was completed on 7/2/24. Resident #14 also had an MDS BIMS score of 15 indicating intact cognition, with diagnoses of coronary artery disease, heart failure, diabetes mellitus, and COPD. The resident stated during interview that she smokes at the facility. Review of the EHR smoking safety evaluation showed the assessment was to be completed quarterly, and the last assessment was completed on 2/10/25. The DON confirmed that smoking assessments should be completed every quarter to evaluate for safe smoking and verified the last assessments completed for both residents.
Failure to Include Enhanced Barrier Precautions in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who utilized an indwelling catheter, as required by professional standards and the Resident Assessment Instrument (RAI). The resident was admitted to the facility from a short-term hospital stay and had a physician's order for a 16 French indwelling Foley catheter to be changed monthly. However, the baseline care plan, signed on February 7, 2025, did not include staff directives to use Enhanced Barrier Precautions, which are necessary for residents with indwelling catheters to prevent infections. During an interview, the Director of Nursing (DON) admitted that the facility did not have a policy on the accuracy of care plans, relying instead on professional standards and the RAI. This oversight resulted in the omission of critical care directives in the resident's care plan, which could potentially impact the resident's health and safety.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to properly secure and store medications, as observed during a survey. On the east hall of the facility, a medication cart was left unlocked and unattended for five minutes by an LPN. During this time, a resident in a wheelchair passed by the unlocked cart. Subsequently, an RN arrived from the south hallway and locked the cart. Interviews with staff, including an RN and the Director of Nursing (DON), confirmed that the expectation is for medication carts to be locked when not in use or out of the nurse's eyesight. However, the facility does not have a specific policy for this practice, relying instead on standards of practice.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents, leading to a deficiency in infection prevention and control. Resident #103 required special treatments including suctioning, tube feedings, and a suprapubic catheter, and had continuous nutrition through enteral feedings. Resident #47, who had severe limited physical mobility due to cerebral palsy, was dependent on staff for all activities of daily living and received nutrition and medication via a PEG tube. During observations, Staff A, an LPN, administered medication and set up enteral feeding for these residents without wearing a gown, which is a requirement under EBP. Resident #26, who had chronic kidney disease and required an indwelling catheter, was also not provided with appropriate EBP. Staff E and Staff F, both CNAs, were observed draining the resident's catheter drainage bag without wearing gowns, although they completed hand hygiene before and after the procedure. Interviews with staff and the Director of Nursing confirmed that the facility's policy required the use of PPE, including gowns, when caring for residents with indwelling medical devices under EBP. The facility's policy, updated in March 2024, specified that EBP should be applied to residents with indwelling medical devices, regardless of MDRO colonization status.
Failure to Rotate Food Items in Accordance with Shelf Life
Penalty
Summary
The facility failed to ensure that food items were replaced before their recommended past due date. During an observation of the facility kitchen, it was discovered that a bin of flour had a date of 10/16/23 on its lid, indicating when it was last filled. The Certified Dietary Manager (CDM) was unsure of the recommended shelf life for flour. Upon consultation with the dietician, it was confirmed that flour in those containers should not be kept for more than six months. The facility's undated policy on Safety in Food Products and Storage indicated that all food products should be rotated, which was not adhered to in this instance.
Lack of Comprehensive Care Plan for Pain Management
Penalty
Summary
The facility failed to provide a comprehensive care plan for a resident, specifically lacking goals and interventions related to pain management and the use of opioids. The resident, who had no cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 14, had a documented diagnosis of pain and a physician's order for Tramadol 50mg PRN every 6 hours. Despite this, the care plan did not include necessary goals and interventions for managing pain with opioids. The Director of Nursing (DON) acknowledged the absence of these elements in the care plan and stated that the facility does not have a specific policy for care plans, instead following the Centers for Medicaid and Medicare Services (CMS) Resident Assessment Instrument (RAI) for care plan completion.
Care Plan Update Deficiency for COVID-19 Positive Resident
Penalty
Summary
The facility failed to update the care plan for a resident who experienced a change in condition, specifically increased weakness, loss of appetite, and a positive COVID-19 diagnosis. The resident, who had a severely impaired cognition with a BIMS score of 4 out of 15, was diagnosed with heart failure, non-Alzheimer's dementia, malnutrition, and urinary retention. Despite the resident's COVID-19 diagnosis and subsequent treatment with an antibiotic and steroid, the care plan lacked specific interventions or monitoring goals to address the resident's needs. The Director of Nursing acknowledged that the facility did not have a specific policy for care plan updates, relying instead on general standards of care.
Inappropriate Catheter Placement and Lack of Dignity Cover
Penalty
Summary
The facility failed to provide appropriate infection prevention practices for a resident with an indwelling catheter. The resident, who had intact cognition, was observed with their catheter drainage bag improperly secured to a trash can containing trash, and the bag lacked a dignity cover. A Certified Nursing Assistant (CNA) confirmed that the catheter was either placed on a barrier on the floor or hung from the garbage can, and dignity bags were not used in the resident's room. The Director of Nursing (DON) stated that the facility's expectation was for the catheter to be placed on a barrier on the ground and not hung on the garbage can. The DON also noted that the facility did not have a specific policy on catheter placement but followed professional standards of practice.
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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 Mapleton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willow Dale Wellness Village | 15.1 mi | ★★★★★ | 2 | 0 |
| Accura Healthcare Of Onawa | 17.5 mi | ★★★★★ | 0 | 0 |
| Pleasant View Care Center | 18.2 mi | ★★★★★ | 0 | 0 |
| Correctionville Specialty Care | 22.3 mi | ★★★★★ | 13 | 0 |
| Dunlap Specialty Care | 24.3 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.