Average — CMS composite of the measures below.
The next survey window likely opens around December 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 Grove Senior Living Llc during CMS and state inspections, most recent first.
Infection control practices were not consistently implemented, as EBP or isolation signage was missing for some resident rooms, a housekeeper emptied trash without gloves or hand hygiene, and the facility lacked a complete documented Legionella water management program. Residents with wounds, an ostomy, or a feeding tube had EBP orders or care plan interventions, but room signage and PPE cues were not consistently posted, and leadership interviews showed gaps in water system monitoring, documentation, and staff knowledge.
Failure to Report Alleged Sexual Abuse Immediately: A resident reported being raped to a CNA and an LPN, but neither staff member notified management or reported the allegation within the required timeframe. The resident had a history of delusions and a pituitary tumor, and staff documented that she appeared calm and without distress, but they still did not report the allegation until it was later discovered during chart review. The DON and Administrator stated all abuse allegations had to be reported immediately regardless of the resident’s mental status or history.
The facility was found deficient in kitchen sanitation practices, including improper use of beard guards by staff, failure to air dry pots and pans, and dirty fans in the dishwashing area. These issues were acknowledged by the Dietary Manager and Administrator, highlighting non-compliance with facility policies.
The facility failed to document the offering and administration of pneumococcal vaccines for three residents, increasing the risk of infection against pneumonia. The facility's policy requires documentation of vaccine administration or refusal, but for three residents, there was no record of follow-up doses being offered or administered. Interviews revealed that staff were unaware of the need for additional doses, leading to this deficiency.
A facility failed to follow infection control guidelines during wound care for a resident with a stage four pressure ulcer and tracheostomy care for another resident under contact isolation. The RN did not disinfect surfaces or change gloves appropriately, and personal items were not cleaned after use in resident rooms. Interviews confirmed these actions were against facility policies.
Infection Control Program Not Properly Implemented
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases. During initial observation, no isolation signage or signage indicating Enhanced Barrier Precautions (EBP) was posted at the entrance or on the doors for rooms 402-A, 407-A, or 433-A. The facility policy stated that infection control precautions, including isolation precautions when necessary, were to follow CDC guidance, and the facility’s EBP signage indicated staff were to clean hands on entry and exit and wear gloves and gowns for high-contact care activities and for residents with devices or skin openings requiring dressings. Resident R4 had diagnoses including diabetes with foot ulcer, peripheral vascular disease, vascular dementia, and kidney disease. R4 had an order for EBP related to a wound, and the care plan identified EBP for a wound requiring dressing with interventions for gown and gloves during high-contact care and wound care. Wound documentation showed a left medial foot wound of long duration. However, observation showed a heel lift bootie on the bed, a laminated stop sign outside the room, and no EBP signage or PPE bin at the room entrance. Resident R5 had diagnoses including vascular dementia, reflux disease, and gastroparesis, and had an order for EBP related to infection control due to an ostomy; observation showed a stop sign and PPE bin, but the Infection Prevention Nurse stated the stop sign meant EBP due to a feeding tube. Resident R8 had diagnoses including heart failure, vascular dementia, peripheral vascular disease, and a pressure ulcer to the left heel, with EBP ordered for a wound and care plan interventions for gown and gloves; observation showed a PPE bin on the bathroom door but no isolation signage posted outside the room or on the door. Housekeeping practice also did not follow infection control expectations. On the 400 hall, a housekeeper was observed entering resident rooms and emptying trash into a larger bag without donning gloves and without performing hand hygiene upon entry or exit. The housekeeper stated she had been trained on infection control and should wear PPE when performing cleaning tasks, including emptying garbage, to avoid spreading germs and keep residents safe. Interviews with the RN, Unit Manager, DON, and Administrator confirmed that proper signage should be posted when needed and that staff should wear gloves and practice hand hygiene when emptying garbage or providing high-contact care. The facility also failed to establish written standards and procedures for a documented water management program based on nationally accepted standards. The Legionella Water Management Program policy stated the program should include a detailed diagram and description of the water system, identify areas where Legionella could grow and spread, and include monitoring and control measures. However, documentation reviewed included only initials on water system flush records without specifics, and a hand-drawn diagram that did not show the entire building water system. The Plant Operation Director stated he did not know what a Legionella risk assessment was, had no training on Legionella, did not have a scheduled process for assessing stagnant water or leaks, was unsure about chlorine monitoring, did not have documentation of water temperature checks, and was unsure whether the facility had flushed lines after a recent water line break. The Administrator also stated the facility had no water diagram.
Failure to Report Alleged Sexual Abuse Immediately
Penalty
Summary
The facility failed to ensure that an allegation of abuse was reported immediately, and no later than 2 hours after it was made, for Resident 16. On 01/09/2026, Resident 16 told CNA 6 and LPN 2 that she had been raped by an unidentified man. CNA 6 and LPN 2 did not report the allegation to administration, and the allegation was not reported to the State Survey Agency until 01/12/2026. Facility policy required alleged abuse to be reported immediately, but not later than 2 hours, and staff were expected to notify management so the investigation and required notifications could occur within that timeframe. Resident 16 was admitted with diagnoses including neoplasm of the pituitary gland, chronic pain syndrome, blindness, insomnia, hoarding disorder, and psychotic disorder with delusions. Her MDS quarterly assessment showed a BIMS score of 15 out of 15, indicating intact cognitive function, although Section E noted delusions as a potential indicator of psychosis. The EMR documented that when she reported the allegation, she stated there was a camera in the ceiling and that whoever had put it there had raped her. LPN 2 documented that she was lying in bed covered and without signs or symptoms of pain or discomfort. Interviews showed that CNA 6 and LPN 2 both heard the allegation and recognized that abuse allegations were supposed to be reported, but they did not report it because they believed the resident’s history of delusions meant the rape had not occurred. CNA 6 stated she told LPN 2 after hearing the allegation, and LPN 2 stated he re-oriented the resident and documented the behavior but did not report it. The DON and Administrator both stated that all allegations of abuse were to be reported immediately regardless of the resident’s diagnosis or past history, and the Administrator stated the allegation was later identified through chart review and the resident was assessed and interviewed.
Deficiencies in Kitchen Sanitation Practices
Penalty
Summary
The facility failed to ensure proper use of beard guards by kitchen staff, as observed during a survey. The Dietary Coordinator and another dietary staff member were seen in the food preparation area with full beards, wearing only surgical masks that did not adequately cover their facial hair. This was contrary to the facility's policy, which mandates the use of beard guards to prevent hair from contaminating food. The Dietary Manager and the Administrator acknowledged the oversight, confirming that beard guards should have been worn. Additionally, the facility did not adhere to its policy regarding the air drying of pots and pans. Several pans were found stacked while still wet, indicating they had not been allowed to air dry as required. This was confirmed by a dietary staff member who acknowledged the error. Furthermore, two fans in the dishwashing area were observed to be dirty, with dust and dirt on the fan cages, posing a risk of contaminating clean dishes. The Dietary Manager and the Administrator both recognized the need for the fans to be clean to prevent contamination.
Failure to Document Pneumococcal Vaccine Administration
Penalty
Summary
The facility failed to document the offering and administration of pneumococcal vaccines for three residents, increasing the risk of infection against pneumonia. The facility's policy, dated March 2024, mandates that all residents be offered pneumococcal vaccines to prevent infections, with documentation required for both administration and refusals. However, for three residents reviewed, there was no documentation of follow-up doses being offered, administered, refused, or received outside the facility. This lack of documentation was identified during a review of the residents' immunization records. Interviews with the Infection Preventionist and the Director of Nursing revealed a lack of awareness regarding the need to offer follow-up pneumococcal vaccinations. The Infection Preventionist was unaware that additional doses were necessary if only one dose had been received, while the Director of Nursing confirmed that the facility was not aware of the requirement to offer additional doses. This oversight led to the deficiency in ensuring residents were adequately protected against pneumococcal infections.
Infection Control Lapses During Wound and Tracheostomy Care
Penalty
Summary
The facility failed to adhere to infection control guidelines during a wound care dressing change for a resident with a stage four pressure ulcer. The resident, who was cognitively intact, had specific physician's orders for wound care, including the use of Anasept topical gel and other dressings. During the dressing change, the RN placed clean dressing supplies on a clipboard and overbed table without disinfecting the surface or using a barrier. The RN also failed to change gloves between cleaning the wound and applying a new dressing, and did not clean the Anasept ointment container before use. Additionally, the clipboard was not disinfected after being used in the resident's room. In another incident, the same RN performed tracheostomy care for a resident with chronic respiratory failure and a tracheostomy, who was also under contact isolation due to shingles. The RN took a personal clipboard into the resident's room and placed it on the overbed table without cleaning it afterward. This action was against the infection control protocols, especially in a contact isolation setting. Interviews with the Infection Preventionist and the Director of Nursing confirmed that the RN's actions were not in line with the facility's infection control policies. The RN admitted to not following best practices, such as not cleaning the overbed table, not changing gloves appropriately, and not disinfecting personal items taken into resident rooms.
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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 Shelbyville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crestview Healthcare And Rehabilitation | 3.3 mi | ★★★★★ | 3 | 0 |
| Signature Healthcare Of Spencer County | 14.3 mi | ★★★★★ | 5 | 0 |
| New Castle Nursing & Rehab | 15.6 mi | ★★★★★ | 0 | 0 |
| Richwood Nursing & Rehab | 15.7 mi | ★★★★★ | 0 | 0 |
| Valhalla Post Acute | 16.1 mi | ★★★★★ | 13 | 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.