Above average — CMS composite of the measures below.
A standard survey is most likely before 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 Lawn Medical Care Facility during CMS and state inspections, most recent first.
The facility failed to implement fall-prevention interventions for two residents with significant cognitive impairment and fall risk. One resident with dementia and a history of repeated falls had a care plan that included 15-minute checks and other safety measures, but the checks were not completed before an unwitnessed bathroom fall that resulted in a head hematoma, a left clavicle fracture, and a brain bleed. Another resident in the secure memory care unit fell while ambulating with a CNA from an OJT program when no gait belt was in use, even though staff stated a gait belt was expected; the care plan did not include gait belt use as an intervention.
Failure to notify the Ombudsman of discharges and transfers. The Ombudsman reported the facility had not been sending notices and had no notices on record for the prior year and current year. The NHA said the ombudsman was emailed monthly, but only 2 emails were available. The NHA also stated there was no written policy for Ombudsman notification, and the SSD said notifications should be done monthly but were only sometimes completed because they forget.
Missing Provider Rationale for Ongoing PRN Ativan Use: A resident with Alzheimer's dementia and severe cognitive impairment was prescribed PRN Ativan for restlessness and anxiousness, but the record did not include provider documentation supporting continued use beyond 14 days. Staff interviews noted the medication was started after increased agitation/restlessness, with a UA and antibiotic also ordered around the same time, and the DON stated the PRN Ativan continued because of a family wedding event.
Failure to Complete SCSA: A resident with atrial fibrillation, hypothyroidism, chronic pain, and a pressure ulcer had an unstageable coccyx wound that progressed to stage 4, along with significant weight loss documented on the quarterly MDS. The MDS also showed >5% weight loss in 30 days, but no SCSA was completed, and the MDS nurse could not explain why.
A resident with dementia experienced undignified treatment when an LPN insisted the resident swallow a new pill despite repeated statements of inability, used vulgar language, and failed to respect the resident's distress during medication administration. The incident was witnessed by a medical assistant and later investigated by the facility.
A resident with Alzheimer's and severe cognitive impairment exhibited combative behaviors during care, resulting in a significant skin tear on the forearm. Despite training on handling difficult behaviors, a CNA continued care without stopping or seeking help, leading to the injury. Staff interviews revealed a lack of consistent documentation and communication about the resident's behaviors, contributing to the deficiency.
The facility failed to conduct proper infection surveillance and reporting, affecting 100 residents. The ICP did not complete written reports since February 2024, only providing verbal updates. Nosocomial infection rates and urinary tract infections without catheters increased, but no root cause analysis or corrective actions were documented. Infection maps lacked proper identification, and the DON was aware of the issues but could not provide evidence of corrective actions.
The facility failed to provide adequate staffing, impacting restorative/mobility services and residents' shower preferences. The Mobility RN was often reassigned to floor duties, leaving residents without recommended mobility care. Residents reported receiving fewer showers than preferred due to staffing shortages, confirmed by EMR records. The DON acknowledged the absence of a restorative program, and the RN Supervisor noted efforts to accommodate additional shower requests when possible.
A facility failed to honor a resident's right to choose his room, resulting in emotional distress. The resident, diagnosed with Major Depressive Disorder, was initially promised a move to a room near his wife, but the plan was canceled due to objections from the wife's family. Despite the resident's right to choose, the facility prioritized family concerns, leading to the resident's increased sadness and frustration.
Two residents in a long-term care facility did not receive necessary restorative services to maintain mobility due to staffing shortages. One resident, with a recent femur fracture, experienced anxiety as restorative services were not initiated after therapy ended. Another resident, with severe dementia and a hip fracture, was not on a restorative plan as the facility had discontinued the program. The Mobility RN was often pulled to work on the floor, affecting the delivery of mobility services.
The facility did not include total nursing hours and actual hours worked on the posted Daily Nurse Schedule, which was accessible to residents and visitors. Interviews revealed that the Nursing Staff Scheduler, DON, and NHA were unaware of the requirement to post actual worked hours, with the schedule only listing the number of staff scheduled to work.
Failure to implement fall-prevention interventions for two residents
Penalty
Summary
The facility failed to implement interventions to prevent accidents for two residents who experienced falls with injury. Resident #2 had diagnoses including dementia, repeated falls, COPD, chronic kidney disease, depression, and chronic pain, and his most recent BIMS score was 7, indicating severe cognitive impairment. His care plan identified him as a fall risk with impulsive self-transfers and included interventions such as 15-minute checks, a low bed with fall mat, and other safety measures. On 06/30/2025, he was found on the bathroom floor during an unwitnessed fall with a head hematoma, left arm discoloration, skin tear, pain to the neck and shoulder, and was sent to the ER. The record review and incident investigation for Resident #2 showed that the 15-minute checks were not completed during the time of the fall. The incident report listed poor safety awareness as the root cause, and the Director of Nursing confirmed that the fall occurred after the last documented 15-minute check at 07:45 a.m. and before the resident was found at 08:30 a.m. The resident was later reported to have been admitted to the hospital with a brain bleed and a left clavicle fracture. The DON also reviewed disciplinary action taken against the CNA for not following the care plan. Resident #6 had dementia, long- and short-term memory impairment, and severely impaired decision-making skills, and lived in the secure memory care unit. On 08/25/2025, the resident was observed with a bruise to the right eye and an abrasion to the nose after a fall. Video footage of the fall showed the resident walking with a CNA from an OJT program, with no gait belt in place, and then turning and falling in the dining room/living room area. The DON stated that a gait belt should have been used, and another CNA reported that staff were always supposed to use a gait belt with this resident. The resident’s care plan did not include gait belt use as a fall-prevention intervention, and the incident report left the root cause blank and did not specify the staff education provided.
Failure to Notify Ombudsman of Discharges and Transfers
Penalty
Summary
The facility failed to provide notice of discharges and transfers to the representative of the Office of the State Long-Term Care Ombudsman. An email from the Long-Term Care Ombudsman received on 8/22/25 stated that the facility had not been sending notices for transfers and discharges and that there were no notices on record for 2024 or 2025. On 8/26/25, the Nursing Home Administrator stated that the ombudsman is emailed monthly by either herself or the social worker, but when asked to provide the monthly emails dating back to the last annual survey, only 2 emails were available, dated 8/14/25 and 8/26/25. On 8/27/25, the Nursing Home Administrator stated that the facility did not have a written policy regarding Ombudsman notification. During an interview the same day, the Social Service Director stated that they were responsible for notifying the Ombudsman of discharges and transfers, that notification should be done monthly, and that it was sometimes done; when asked why it was not done consistently each month, they reported that they forget.
Missing Provider Rationale for Ongoing PRN Ativan Use
Penalty
Summary
The facility failed to ensure clinical rationale was documented by the provider for the ongoing use of a PRN anti-anxiety medication beyond 14 days for one resident with Alzheimer's dementia. The resident's MDS reflected long- and short-term memory impairment and severely impaired cognitive skills for daily decision making. The clinical record showed the resident was prescribed Ativan 0.5 mg PRN three times daily for restlessness and anxiousness, and a urinalysis was ordered the same day, followed by an antibiotic order the next day. The record did not include documentation from the physician or provider explaining why the PRN Ativan continued beyond the 14-day period after it was ordered. During interviews, the DON stated the facility still used paper charts, and the SW reported the nurse contacted the physician because of increased agitation and restlessness. The SW also stated the resident had a lot of anxiety and agitation, and noted the family wanted the resident able to participate in a family wedding in the courtyard. A later interview with the DON indicated the Ativan continued beyond 14 days because of the wedding and that the order would change after the event.
Failure to Complete Significant Change in Status Assessment
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident whose condition changed in more than one area. The resident was admitted with diagnoses including atrial fibrillation, hypothyroidism, gastroesophageal reflux, chronic pain, a sacral pressure ulcer, osteoarthritis, hyperkalemia, bradycardia, a history of pacemaker, and urinary retention. The resident’s MDS with an ARD of 08/07/2025 showed a BIMS score of 13, indicating cognitive intactness, and the quarterly assessment documented an unstageable pressure ulcer and greater than 5% weight loss in the last 30 days. The medical record showed the coccyx wound was first identified as unstageable on 07/10/2025 and had progressed to stage 4 on the most recent skin evaluation completed on 08/25/2025. The resident’s weight decreased from 168 lbs. on 07/03/2025 to 153 lbs. on 08/07/2025, and a progress note dated 08/25/2025 documented the resident was down 9% in 30 days, 16% in 90 days, and 15% in 180 days. The MDS history did not show that an SCSA was completed, and during interview the MDS nurse confirmed the quarterly assessment reflected an unstageable pressure ulcer and 5% weight loss in 30 days but could not explain why the SCSA had not been completed.
Failure to Ensure Dignified and Respectful Medication Administration
Penalty
Summary
A resident with dementia and behavioral disturbances was subjected to undignified treatment during medication administration. According to facility documentation and staff interviews, a Licensed Practical Nurse (LPN) entered the resident's room to administer a new stomach pill that could not be crushed. The resident was lying flat in bed and repeatedly expressed an inability to swallow the pill, with water running out of his mouth onto his chest. Despite these difficulties, the LPN continued to insist that the resident swallow the pill and used vulgar language during the interaction. The resident verbally expressed distress, stating that the nurse was killing him. A Medical Assistant present in the room corroborated the resident's repeated statements of being unable to swallow the pill and reported the LPN's use of inappropriate language. The facility's investigation found that the resident had no recollection of the incident when later interviewed by a social worker. The LPN involved had received education on resident rights in the previous three years. The incident was reported after the resident's death, and the LPN was not available for interview during the investigation.
Failure to Implement Person-Centered Care for Dementia Resident
Penalty
Summary
The facility failed to develop and implement person-centered care approaches for a resident diagnosed with dementia, leading to a significant injury. The resident, who was admitted with Alzheimer's and had severely impaired cognitive skills, was observed to have behaviors of being combative during care. On one occasion, while a Certified Nurse Aide (CNA) was providing morning care, the resident became combative, resulting in a severe skin tear on the right forearm. The injury was significant enough to require emergency room treatment, where it was noted that the tissue was avulsed to the subcutaneous fat, exposing muscle. The CNA reported that the resident exhibited combative behaviors daily during care, including swatting at staff and twisting her own arms. Despite these behaviors, the CNA continued to provide care without stopping or seeking additional assistance, which was contrary to the training received on handling difficult behaviors in residents with dementia. The CNA admitted to not stopping the care when the resident became combative, which likely contributed to the injury. Interviews with staff revealed that the resident's aggressive behaviors were known, but there was a lack of consistent documentation and communication regarding these behaviors. The Social Worker noted that behavior logs were discontinued due to being blank, and the Nursing Home Administrator and Director of Nursing confirmed that staff training emphasized ensuring resident safety and reapproaching if issues arose during care. However, these protocols were not effectively implemented in this case, leading to the deficiency.
Inadequate Infection Surveillance and Reporting
Penalty
Summary
The facility failed to provide appropriate infection surveillance for all residents, impacting 100 current residents, and did not take necessary actions to track, trend, and formulate corrective actions to decrease the spread of nosocomial infections. The Infection Control Preventionist (ICP) C, who has been in the position since February 2024, was responsible for data collection and review regarding infections. However, ICP C had not completed written reports since February 2024, citing being busy as the reason, and only provided verbal reports to the Infection Control Committee and Quality Assurance Committee. Despite the presence of nosocomial infection rates and urinary tract infections without catheters, no root cause analysis or corrective actions were documented. The facility's line listing showed fluctuating nosocomial infection rates and an increase in urinary tract infections without catheters, yet no reports were provided to address these issues. Infection maps lacked proper identification of community-acquired or in-house acquired infections, as indicated by the map legend. The Director of Nursing (DON) B acknowledged the expectation for monthly reports and was aware of the increase in urinary tract infections but could not provide evidence of education or actions taken in response. Additionally, the Quality Assurance Minutes inaccurately recorded that ICP C presented reports, despite the absence of completed reports after February 2024.
Inadequate Staffing Affects Mobility Services and Shower Frequency
Penalty
Summary
The facility failed to ensure adequate staffing to meet the needs of residents, specifically in providing restorative/mobility services and honoring residents' preferences for shower frequency. The facility assessment indicated that 102 residents required assistance with bathing, yet there were no restorative nursing assistants available, and the facility planned to add two staff once staffing levels were reached. Interviews revealed that the Mobility RN was frequently pulled from her duties to work as a floor nurse, resulting in residents not receiving recommended mobility services. The Director of Nursing (DON) confirmed the absence of a restorative program since January 2024 and stated that CNAs were needed on the floor, impacting the mobility program. Additionally, residents expressed dissatisfaction with the frequency of showers, preferring two showers per week, but were informed by staff that there was insufficient staffing to accommodate this preference. The Electronic Medical Record (EMR) confirmed that residents were receiving showers only once per week. The RN Supervisor explained that staff scheduled for baths and showers were not assigned to general care, and efforts were made to accommodate additional shower requests if possible. However, the lack of adequate staffing hindered the facility's ability to meet residents' preferences consistently.
Failure to Honor Resident's Right to Room Choice
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not allowing a resident to relocate to a room of his choice, which was across from his wife's room. This decision resulted in emotional distress for the resident, who expressed feelings of frustration, anger, and depression. The resident, who has a diagnosis of Major Depressive Disorder and intact cognition, was initially informed that he could move to a room closer to his wife. However, the plan was canceled by the Nursing Home Administrator due to objections from the wife's family, despite the resident's expressed desire and right to make this choice. The resident's emotional state was further documented in a psychiatry note, which indicated that he felt lied to and was experiencing increased sadness and sleep disturbances due to the situation. The Social Worker confirmed that the resident technically had the right to choose his room, but the facility's decision was influenced by the family's concerns. The resident's ongoing distress was evident during observations, where he was noted to have a flat affect and expressed bitterness about the situation, stating that he would not feel good until he could be near his wife.
Failure to Provide Restorative Services Due to Staffing Shortages
Penalty
Summary
The facility failed to provide restorative services to maintain mobility for two residents, resulting in anxiety and unmet goals. Resident #98, who had a left femur fracture repair, was observed sitting in a wheelchair and expressed anxiety due to the lack of restorative nursing services after her therapy ended. Despite recommendations for a range of motion program, the services had not started, and there was a lack of communication regarding her participation in scheduled exercise activities. The Mobility RN confirmed that Resident #98 was not on a restorative/mobility program due to staffing shortages. Resident #44, who had multiple diagnoses including severe vascular dementia and a recent hip fracture, was also not receiving restorative services. After being readmitted to the facility following a fall and surgical repair, Resident #44's therapy was discontinued, and a restorative program was supposed to start. However, the Director of Nursing stated that the facility had not had a restorative program since January 2024, and the mobility program was also affected by staffing issues. The Mobility RN, who was responsible for the program, was frequently pulled to work on the floor, limiting the number of residents she could see. Both residents experienced a lack of restorative care due to insufficient staffing, which led to the discontinuation of the facility's restorative and mobility programs. The facility's inability to provide these services resulted in unmet goals for maintaining the residents' mobility and contributed to Resident #98's anxiety. The report highlights the facility's failure to follow through with recommended care plans due to staffing constraints.
Failure to Post Actual Nursing Hours Worked
Penalty
Summary
The facility failed to include daily nursing total numbers and actual hours worked on the posted Daily Nurse Schedule, which was accessible to residents, family, and visitors. During an interview, the Nursing Staff Scheduler was unable to provide the total number of hours to be worked for each shift or the total number of hours worked for previous shifts. The document posted, titled Daily Nurse Schedule, only listed the names and shifts of the staff scheduled to work on that date, without indicating the total hours to be worked. Further interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) revealed that neither was aware of the requirement to post actual worked hours. The NHA explained that the schedule only listed the total number of persons working, and anyone reviewing the hours would have to calculate the total hours themselves. The NHA requested information on the requirement to post actual worked hours, indicating a lack of awareness of this regulatory requirement.
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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 Coldwater
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Laurels Of Coldwater | 0.7 mi | ★★★★★ | 7 | 0 |
| Hillsdale County Medical Care Facility | 17.8 mi | ★★★★★ | 14 | 0 |
| Hillsdale Hospital Mcguire & Macritchie Long Term | 18.4 mi | ★★★★★ | 2 | 0 |
| Northern Lakes Nursing And Rehabilitation Center | 20.1 mi | ★★★★★ | 9 | 2 |
| Lakeland Rehab And Healthcare Center | 20.1 mi | ★★★★★ | 6 | 0 |
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