Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Manor Village during CMS and state inspections, most recent first.
A resident who elected hospice had a significant change in status, but the MDS assessment was not completed within the required 14-day timeframe. The resident’s hospice consent and election forms were signed, and a progress note documented the planned hospice admission, yet the MDS lacked a completion date. The DON reported there was no MDS Coordinator, and the MDS/Reimbursement Specialist stated she was unaware of the 14-day requirement tied to hospice election.
Controlled substance records were inconsistent for several residents, including missing narcotic tablets, a missing card, and a clonazepam dose documented as given hours before the ordered time. MARs, count sheets, and progress notes did not match for multiple PRN opioids, and video review showed an LPN handling several narcotic cards and placing multiple pills into one medication cup while the DON later found altered count entries and unexplained discrepancies.
Failure to Discontinue Anticoagulant After Hospital Discharge: A resident returned from the hospital with discharge instructions to stop Eliquis, but the MAR continued the anticoagulant and the resident received 4 doses after return. The DON stated she transcribed the order and missed the discontinuation instruction in the discharge paperwork, despite the resident’s hospital diagnosis of melena and history of anemia.
The facility inaccurately coded MDS assessments for two residents, documenting insulin administration when only Ozempic was given for type 2 diabetes. Staff interviews confirmed the error, as the TARs lacked insulin orders, highlighting a documentation deficiency.
A resident with severe intellectual disabilities and other diagnoses exhibited picking behavior at a recliner's footrest, which was not addressed in their care plan. Despite staff presence, no interventions were made to redirect the behavior. The facility lacked a specific policy for managing such behaviors, and the care plan did not document or include measures to prevent the behavior.
A resident with intact cognition reported that staff broke his bottom denture during cleaning, and the facility failed to arrange for repair or replacement. Despite the resident's request for a dental appointment, staff were unaware of the issue's duration and faced challenges finding a dentist who accepted the resident's insurance. The facility did not follow its policy to promptly refer the resident for dental services, leading to the deficiency.
The facility failed to ensure that a dietary aide completed dependent adult abuse training within 6 months of hire. The aide, hired 7 months prior, had not previously taken the training and was completing it for the first time. The facility's policy requires this training within 6 months, which was confirmed by Human Resources and the administrator.
Late MDS Completion After Hospice Election
Penalty
Summary
The facility failed to complete a significant change MDS assessment within 14 days of a resident’s status change for Resident #41, who elected hospice care. Resident #41’s hospice admission consent form, Medicare Hospice Benefit Election form, and Election of Medicaid Hospice Benefit form were signed and dated on 12/5/2025, and a progress note at 10:00 AM that day documented the resident would be admitted to hospice later that day. The RAI 3.0 User’s Manual stated that hospice enrollment is a significant change and that the MDS assessment must be completed no later than 14 calendar days after the determination of the significant change. The resident’s MDS dated [DATE] lacked a completion date. On 2/16/26, the DON reported the facility did not currently have an MDS Coordinator and had been using an offsite group to complete MDSs since late November. On 2/17/26, the MDS/Reimbursement Specialist stated she did not know about the 14-day requirement from hospice election and realized it when reviewing the RAI manual table showing the determination date plus 14 days to complete.
Controlled Substance Counts and Documentation Were Inconsistent
Penalty
Summary
The facility failed to ensure controlled substances were not diverted for five residents. During review of medication carts, one narcotic pill was missing from the controlled substance drawer for each of four residents, and one resident’s controlled substance card was missing when the count was checked. The report also identified that a clonazepam card for one resident showed the medication was administered at 7:20 a.m. even though the order was for noon, and there was no documentation supporting early administration or a physician order allowing it. Resident #1 had diagnoses including anxiety, reduced mobility, and diabetic polyneuropathy, with MDS data showing severe cognitive impairment on one assessment and intact cognition on another. The resident had chronic pain related to a sacral pressure ulcer and osteoarthritis of the right hip, and the MAR showed hydrocodone-acetaminophen was given as needed for severe pain. The controlled substance record showed discrepancies in the count, and the FRI documented one tablet unaccounted for. Resident #2 had anxiety disorder, intellectual disabilities, and mood disorder, with severe cognitive impairment and behavioral symptoms. The MAR ordered clonazepam 0.5 mg daily at noon, but the controlled substance record showed it was signed out at 7:20 a.m., the card was missing from the drawer, and Staff A stated the medication had been given early even though she knew she was not supposed to do that. Resident #3 had chronic pain syndrome and postlaminectomy syndrome, with intact cognition and pain almost constantly during therapy, sleep, and daily activities. The MAR and controlled substance record did not match for oxycodone administration, and the FRI found one tablet unaccounted for. Resident #4 had a right humerus fracture with moderately impaired cognition and pain almost constantly, and the MAR and controlled substance record showed discrepancies for oxycodone, including an entry that was scribbled over and a count that left two tablets unaccounted for. Resident #5 had chronic pain and severe cognitive impairment, and the controlled substance record showed hydrocodone-acetaminophen entries that did not match the MAR, including a count change that was altered and another dose signed out on the controlled substance record but not on the MAR. Interviews and video review showed Staff A handling multiple narcotic cards, writing on the controlled substance record, and appearing to place several pills into one medication cup, while the facility’s controlled substance count policy required accurate shift-to-shift counts, double-lock storage, and proper documentation of administration and wasting.
Failure to Discontinue Anticoagulant After Hospital Discharge
Penalty
Summary
The facility failed to discontinue Eliquis in accordance with the discharging hospital physician’s orders for Resident #1. After the resident returned from the hospital, the Medication Administration Record continued to direct administration of Eliquis 2.5 mg twice daily for atrial fibrillation, even though the hospital discharge summary printed on 9/22/25 directed that Eliquis 2.5 mg be stopped. As a result, the resident received the supper dose on return to the facility, then received two doses the next day and the morning dose the following day, for a total of 4 doses after the hospital had ordered the medication discontinued. Resident #1’s record showed diagnoses including anemia and anxiety, a BIMS score of 15 out of 15, and that the resident was always incontinent of stool. The hospital discharge diagnosis was melena, and the discharge medication list specifically instructed to stop Eliquis. The DON stated she was the one who wrote the Eliquis order and explained that she missed the discontinuation instruction because she skimmed over it and only saw the medication listed above it. The facility policy stated that active orders should be followed and carried out as written or transcribed.
Inaccurate MDS Coding for Diabetes Management
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents, leading to a deficiency. Resident #8 and Resident #16 were both documented as having received insulin injections during the lookback period of their MDS assessments. However, a review of their Treatment Administration Records (TAR) revealed no orders for insulin. Instead, both residents had orders for Ozempic, a medication used to treat type 2 diabetes mellitus, which is not classified as insulin. Interviews with facility staff confirmed the discrepancy. Staff A, an LPN, acknowledged that both residents had a diagnosis of type 2 diabetes mellitus and received Ozempic, not insulin. Staff B, an RN and Assistant Director of Nursing, along with Staff C, an RN and MDS Coordinator, confirmed that the MDS assessments incorrectly documented the administration of insulin. The facility's Administrator acknowledged that the Resident Assessment Instrument (RAI) manual was followed for MDS completion, yet the error in documentation persisted.
Failure to Address Behavioral Health Concerns in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan addressing the behavioral health concerns of a resident with severe intellectual disabilities and other diagnoses, including epilepsy and a psychotic disorder. The resident exhibited behaviors such as picking at a hole in the footrest of a recliner, which was observed multiple times without staff intervention. Despite the presence of staff and other residents in the common area, no attempts were made to redirect the resident or provide alternative activities to mitigate the behavior. The resident's care plan did not document the picking behavior or include interventions to prevent it. Although the care plan included general strategies for managing anxiety and behaviors, such as offering snacks or engaging in activities, it lacked specific measures to address the observed behavior. Interviews with the Director of Nursing and the Administrator revealed that the facility did not have a policy specific to managing such behaviors, and there was uncertainty about whether the behavior was due to unmet needs or simply a characteristic of the resident's condition.
Failure to Provide Dental Services for Resident with Broken Dentures
Penalty
Summary
The facility failed to provide or ensure dental services for a resident who had broken dentures. The resident, who had intact cognition, reported that the staff dropped and broke his bottom denture during cleaning. Despite the resident's request for a dental appointment, the facility did not arrange for the repair or replacement of the dentures. Staff interviews revealed a lack of awareness about the duration of the issue and difficulties in finding a dentist who accepted the resident's insurance. The facility's policy required prompt referral for damaged dentures within three days and documentation of actions taken to ensure the resident could eat and drink while waiting for dental services. However, the facility did not adhere to this policy, as the resident continued to experience issues with chewing due to the broken dentures. The facility's failure to address the resident's dental needs in a timely manner led to the deficiency identified in the report.
Failure to Complete Dependent Adult Abuse Training Within Required Timeframe
Penalty
Summary
The facility failed to ensure that staff completed dependent adult abuse training within 6 months of hire for one of the five employees reviewed. The employee file for a dietary aide, hired on 9/1/23, contained a training certificate dated 4/2/24, which is 7 months post-hire. The facility's policy requires new employees to complete the mandatory reporter training within 6 months if they have not previously taken a state-approved curriculum. During interviews, the Human Resources staff confirmed the hire date and acknowledged the delay in training completion. The dietary aide confirmed that he was taking the training for the first time on 4/2/24, and the administrator stated that the training is expected to be completed within the required timeframe.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Village Of Ackley | 9.2 mi | ★★★★★ | 8 | 0 |
| Rehabilitation Center Of Allison | 12.5 mi | ★★★★★ | 7 | 0 |
| Grundy Care Center | 16.5 mi | ★★★★★ | 15 | 0 |
| Creekside | 16.6 mi | ★★★★★ | 6 | 0 |
| Clarksville Skilled Nursing & Rehab Center | 17.2 mi | ★★★★★ | 2 | 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.