Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Woods Manor during CMS and state inspections, most recent first.
A resident admitted with stroke, pneumonia, dysphagia, and type 2 DM, and ordered NPO with PEG tube feeding and insulin, experienced neglect when staff changed the ordered Glucerna formula to Jevity without rationale and significantly delayed initiation of tube feeding and water flushes. Facility staff failed to enter and follow discharge insulin orders on admission, did not start oral DM medication and basal insulin until nearly two weeks later, and did not consistently act on repeated BG readings over 300–500+ despite a policy to notify a practitioner for BG >400. Therapy staff and CNAs reported progressive lethargy, weakness, and increased dependence for transfers, while the record lacked nursing assessments of change in condition, respiratory assessments or monitoring for pneumonia, documentation of antibiotic use for pneumonia, or PEG site assessments. EMS later documented that staff reported the resident had been in an altered mental status with BG levels above 500 for several days before transfer, and hospital records showed admission for altered mental status, severe hypernatremia, hyperglycemia, AKI, and sepsis, demonstrating that the resident’s change in condition went unrecognized and undocumented by facility nursing staff.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failure to ensure that treatment and supports for daily living were delivered safely to residents.
A resident who was fully dependent and non-ambulatory exhibited increased pain and abnormal behaviors over several days, which were observed and reported by multiple CNAs to nursing staff. Despite these reports and visible signs such as an externally rotated leg, nursing staff did not conduct or document a thorough assessment, and no timely pain management was provided. The resident was only sent to the hospital after family intervention, where bilateral femoral neck fractures were discovered. The facility lacked a pain management policy and did not follow its change in condition notification policy, resulting in delayed recognition and treatment.
The facility failed to maintain appropriate hot water temperatures and chlorine levels, crucial for preventing Legionella growth. Despite policies for daily temperature checks, records showed inconsistent monitoring, with many readings below recommended levels. Maintenance staff acknowledged issues with a mixing valve and inconsistent temperature checks, creating potential risks for residents.
The facility failed to document and make accessible the code status of six residents, leading to potential miscommunication of treatment preferences. For one resident, the EMR lacked clear code status information, and the care plan did not reflect their wishes. Similar issues were found for other residents, with staff relying on a cumbersome binder system not part of the official medical record. The facility's policy did not ensure easy access to code status information.
The facility failed to conduct timely assessments and maintenance checks for enabler bars for several residents, leading to a deficiency in care. A resident had enabler bars without a care plan, and maintenance logs were incomplete. Another resident's assessments were delayed, and maintenance documentation was unclear. A third resident had no follow-up assessments after the initial one. The facility's policy required quarterly evaluations, which were not followed, indicating a systemic issue.
A facility failed to include a resident and his representative in the care planning process. Despite the resident having full cognitive abilities, he was not involved in any care planning meetings, and his wife, who is his representative, was not asked to participate in a care conference. The Clinical Care Coordinator confirmed that no interdisciplinary team members were present during the meeting with the wife, and there was no documentation of the meetings. This oversight contradicts the facility's policy on collaborative care planning.
The facility failed to update care plans for two residents, one with a suspected deep tissue injury and another with significant weight loss. The care plans did not reflect the current conditions or interventions, leading to deficiencies in care management.
A resident with multiple diagnoses, including paraplegia and heart failure, was observed with a hand brace provided by her daughter, but the facility failed to document, assess, or monitor its use. Despite an order for the brace, there was no documentation in the EMR, MAR, TAR, or care plans, and staff interviews confirmed the absence of a restorative nursing department. This lack of documentation and monitoring constitutes a deficiency in care.
A resident experienced new visual hallucinations and delusions, reporting seeing cats and rats in her room. Despite these symptoms being noted by staff on multiple occasions, the facility failed to act promptly, with no immediate assessment or monitoring conducted. The issue was only addressed during a survey process, highlighting a deficiency in the facility's response to the resident's change in mental status.
A facility failed to prevent a pressure ulcer for a resident and ensure timely skin assessments for another. One resident's pressure ulcer worsened due to a delay in replacing a worn wheelchair cushion, while another resident's skin issues were not promptly identified due to missed assessments. The facility did not adhere to its skin care protocols, contributing to these deficiencies.
A resident's enteral nutrition was administered at an incorrect rate, contrary to physician orders, and the DPOA was not informed of the change. Additionally, there were no documented orders for the routine care of the resident's PEG tube site. The facility's policy on resolving discrepancies before medication administration was not followed.
A facility failed to follow policies for skin and wound assessments, resulting in pressure ulcers in three residents. One resident developed a Stage III ulcer and multiple deep tissue injuries due to inconsistent repositioning and lack of documentation. Another resident developed Stage II and IV ulcers, with inadequate care plans and infection control breaches during dressing changes. A third resident's skin assessments were not conducted regularly. The facility's policies for weekly assessments and documentation were not followed, leading to these deficiencies.
Neglect in Enteral Nutrition, Diabetes Management, and Infection Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect related to enteral nutrition, diabetes management, and monitoring for infection and respiratory status. The resident was admitted with diagnoses including cerebral infarction, pneumonia, dysphagia, and type 2 diabetes, and was NPO with orders for PEG tube feeding using Glucerna 1.5 at a specified rate, along with insulin lispro on a sliding scale. Upon admission, the facility changed the ordered Glucerna to Jevity 1.5 without documented rationale and did not initiate tube feeding until many hours after admission, with documentation showing Jevity first administered approximately 23 hours after admission and water flushes about 6 hours after admission. The resident’s insulin from the hospital discharge orders was not entered and administered on admission; instead, the facility delayed ordering and starting diabetic medications, with oral Jardiance initiated about 13 days after admission and Lantus insulin about 14 days after admission. The facility did not consistently follow its own parameters and standing orders for hyperglycemia management and failed to timely intervene or notify practitioners despite numerous critically elevated blood glucose readings. Facility policy required notifying the practitioner when blood sugar exceeded 400, yet the resident’s blood sugars were above 300 on at least 29 occasions and repeatedly above 400, including readings of 435, 455, 509, and 510, without documented timely intervention or consistent communication to the practitioner. Progress notes show that on one day a blood sugar of 510 led to an order for 20 units of regular insulin and that the resident’s wife reported noticing a change in condition days earlier and requested transfer to the emergency room. However, there was no documentation of ongoing nursing assessments addressing the persistently elevated blood sugars, no A1C results despite being ordered, and the DON acknowledged that the facility could not identify who was closely monitoring these levels or provide other interventions implemented during the period of sustained hyperglycemia. The facility also failed to assess and document the resident’s pneumonia, respiratory status, and PEG tube site, and did not maintain adequate documentation of changes in condition leading up to the resident’s transfer to the hospital. The resident was admitted on an antibiotic for pneumonia, but the record lacked respiratory assessments, monitoring of pneumonia progression or improvement, documentation of antibiotic use related to pneumonia, or a short-term care plan for this diagnosis. Therapy staff and CNAs reported that over time the resident became increasingly lethargic, weak, and more dependent for transfers, with observations of posterior lean, difficulty with transfers, dizziness, and appearing as “dead weight,” and a speech therapist documented concern for a change in status that was communicated to nursing and the NP. Despite these reports, there were no corresponding nursing assessments or transfer forms in the record. EMS documentation indicated that staff reported the resident had been in an altered mental status with blood glucose levels sustained above 500 for several days prior to transfer, and hospital records described admission for altered mental status, hypernatremia, hyperglycemia, acute kidney injury, and sepsis. The DON and Administrator were unable to locate documentation of PEG site assessments or explain the lack of pneumonia-related assessments and monitoring, confirming gaps in required nursing assessment and documentation. The combination of delayed initiation and inappropriate change of enteral nutrition, failure to follow discharge insulin orders or timely implement diabetes treatment, lack of timely intervention and communication regarding persistently elevated blood glucose levels, and absence of documented respiratory and PEG site assessments for an admitted pneumonia diagnosis constituted neglect of the resident’s care needs. These inactions and omissions led to an unnoticed and undocumented change in condition that ultimately required hospitalization, as evidenced by EMS and hospital records describing the resident’s deteriorated state at the time of transfer.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that residents did not consistently receive treatment and supports for daily living in a manner that ensured their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Assess and Document Change in Condition Resulting in Delayed Pain Treatment
Penalty
Summary
A deficiency occurred when staff failed to promptly assess and document a change in condition for a fully dependent, non-ambulatory resident with multiple comorbidities, including dementia, schizoaffective disorder, and heart failure. The resident exhibited increased pain and abnormal behaviors, such as intense rocking, grimacing, and vocalizations, which were observed by several CNAs and reported to nursing staff. Despite these observations, nursing staff attributed the behaviors to the resident's baseline diagnoses and did not conduct or document a thorough assessment or follow-up, even when the resident's leg was noted to be externally rotated and he displayed pain upon touch. Multiple staff members, including CNAs and nurses, reported noticing the resident's increased discomfort and abnormal leg positioning over several days. These changes were communicated during shift reports and to the responsible nurse, but no progress notes or assessments were completed to address the resident's change in condition. Pain assessments documented a score of zero on the day the leg abnormality was discovered, and pain medication was administered only twice in the days preceding the event. The resident's family member ultimately insisted on hospital transfer, where imaging revealed acute, complete bilateral femoral neck fractures. The facility's investigation did not identify abuse or neglect but concluded that the injuries were likely subacute and possibly pathological in nature. However, the lack of timely assessment, documentation, and communication with the medical director regarding the resident's increased pain and change in condition resulted in a delay in treatment and recognition of the fractures. The facility did not have a specific pain management policy, and staff failed to follow the existing policy for change in resident condition, which required physician and family notification for significant changes.
Failure to Maintain Safe Water Temperatures and Chlorine Levels
Penalty
Summary
The facility failed to monitor and respond to abnormally low hot water temperatures, which is crucial for the prevention and management of Legionella. The Infection Prevention and Control (IPC) Nurses and the Maintenance Director were responsible for reviewing the water management program and monitoring water for Legionella. However, there was a lack of communication and awareness about any issues with the water system, as the IPC Nurse was not informed of any problems. The water management program book showed outdated testing, with the last test conducted in 2023, and the Administrator provided conflicting information about the testing dates. The facility's water testing results indicated that the chlorine levels in certain areas were significantly below the required minimum, and the hot water temperatures were not maintained at the recommended levels. The Corporate Maintenance Director acknowledged that the water temperatures were often below 110 degrees Fahrenheit, which is below the recommended range of 114-118 degrees Fahrenheit due to low chlorine levels. Despite the facility's policy to test water temperatures daily, there were many days without recorded temperatures, and the facility did not consistently test on weekends. The facility's water temperature records revealed numerous instances of temperatures below the recommended levels, with some readings even below 100 degrees Fahrenheit. Maintenance staff admitted to not taking daily temperature checks consistently and acknowledged issues with a mixing valve. The facility's failure to maintain appropriate water temperatures and chlorine levels, as well as the lack of consistent monitoring, created conditions conducive to the growth of Legionella, posing a potential risk to the residents.
Deficiency in Documenting and Accessing Residents' Code Status
Penalty
Summary
The facility failed to ensure that the code status of six residents was documented and accessible in their medical records, which could lead to miscommunication regarding their treatment preferences. For Resident #12, the electronic medical record (EMR) did not clearly indicate the resident's code status, and the physician's order only referred to a Preferred Treatment Option without specifying the details. Additionally, the care plan for Resident #12 did not mention the code status, and similar issues were found for Residents #21, #53, #79, and #158, where the EMR contained forms with options but lacked specific orders or care plans reflecting the residents' wishes. Resident #92, who had moderate cognitive loss and was receiving hospice services, also had no clear documentation of code status in the medical record. The Clinical Care Coordinator acknowledged the absence of specific orders or care plans for code status and mentioned that staff would need to search through the EMR or refer to a binder at the nurse's desk to find this information. However, the binder was not part of the official medical record, and the process of locating a resident's code status was cumbersome due to the binder's organization. During interviews, it was revealed that the binders containing code status information were difficult to navigate, and some documents, like the one for Resident #92, were of poor quality and unreadable. The facility's policy on Advanced Directives did not provide a clear process for ensuring that residents' code status was easily accessible in the medical record, contributing to the deficiency in maintaining accurate and accessible documentation of residents' treatment preferences.
Failure to Conduct Timely Assessments and Maintenance for Enabler Bars
Penalty
Summary
The facility failed to complete necessary assessments and maintenance checks for enabler bars for four residents, leading to a deficiency in care. Resident #2 was observed with bilateral enabler bars affixed to her bed, but her care plan did not include any information related to these bars. The maintenance logs for Resident #2 were incomplete, with no record of the initial four-day monitoring after installation. The Maintenance Director confirmed that the resident needed the enabler bars, but there was no documentation to support this need. Resident #71 had a care plan for assist rails to enhance mobility, but the quarterly assessments for the continued use of enabler bars were not completed on time. The last assessment was five months late. The maintenance logs were unclear, with an 'X' next to the room number, making it uncertain whether the enabler bars were inspected for safety and functionality. Similarly, Resident #76's assessments were not completed at the appropriate intervals, and the maintenance logs showed lines through the initial monitoring days, indicating a lack of clarity in the documentation. Resident #75 had an initial assessment for enabler bars, but no subsequent assessments were completed. The facility's policy required quarterly evaluations of residents' need for rails, which was not adhered to. The Clinical Care Coordinator acknowledged the responsibility of unit managers to ensure assessments were completed, but the last monthly audits of enabler bars were conducted months prior, indicating a systemic issue in maintaining compliance with the facility's policies.
Failure to Include Resident in Care Planning
Penalty
Summary
The facility failed to include and document the participation of a resident and his representative in the care planning process. The resident, who had been at the facility for nearly three weeks, was not involved in any care planning meetings. His wife, who is his representative, reported that she had not been asked to participate in a care conference or care planning meeting with the resident and the facility. The resident confirmed that he had not been included in any care planning meetings. The resident's medical history includes dementia, heart failure, kidney failure, an intestinal disorder, sepsis, a history of falls, rib fractures, and gait and mobility abnormalities. Despite having full cognitive abilities, as indicated by a BIMS score of 13/15, the resident was not involved in the care planning process. The Clinical Care Coordinator (CCC) responsible for conducting care conferences stated that a meeting was held with the resident's wife over the phone, but no other staff from the interdisciplinary team was present. The CCC also confirmed that the resident was not included in the meeting and that there was no documentation of the meetings with the resident or his wife. A review of the facility's policy on the care planning process emphasized the importance of a collaborative partnership with the interdisciplinary team, resident, and/or resident representative, and the need to provide an opportunity for the resident to participate in planning care and treatment changes. However, this policy was not followed in the case of this resident.
Failure to Update Care Plans for Skin and Nutrition
Penalty
Summary
The facility failed to timely revise and update care plans for two residents, resulting in care plans not reflecting the current status and needs of the residents. Resident #33, who has a history of dementia, major depressive disorder, chronic systolic heart failure, anxiety, and hypertension, was found to have a suspected deep tissue injury (SDTI) on her right heel and ankle. Despite this, the care plan for skin impairment had not been revised since February and did not mention the current skin conditions. The Unit Manager acknowledged that the care plan should have been updated to include a short-term care plan for the SDTI and the actual skin issue, but it was only revised after being notified of the oversight. Resident #63, with diagnoses including dementia, major depressive disorder, encephalopathy, and hypertension, experienced a significant weight loss of 17% over six months. Despite being started on supplement shakes to aid in weight gain, the care plan for nutrition had not been updated since 2021 and did not include a specific plan for addressing the weight loss. The Certified Dietary Manager admitted to not creating a specific care plan for weight loss, instead incorporating it into the general nutritional care plan. This lack of timely updates and specific care plans for the residents' changing conditions led to deficiencies in their care management.
Failure to Document and Monitor Hand Brace for Resident
Penalty
Summary
The facility failed to ensure proper documentation, assessment, and monitoring of a hand brace/splint for a resident who was reviewed for rehab and restorative services. The resident, who was observed with a splint/brace on her right hand, reported that her daughter had provided the brace and staff assisted her in putting it on and off. However, the resident did not perform any exercises for her right hand or arm. The resident's medical records, including the Face sheet, Minimum Data Set (MDS) assessment, and physician orders, indicated that she had multiple diagnoses, including paraplegia, heart failure, COPD, diabetes, and others. Despite an order allowing the use of a soft brace, there was no documentation of restorative services or assistance with the brace in the electronic medical record (EMR), Medication Administration Record (MAR), Treatment Administration Record (TAR), or care plans. Interviews with facility staff, including the Therapy Director and Clinical Care Coordinator, revealed that the facility did not have a dedicated restorative nursing department, but nurse aides were trained to perform restorative functions. The Clinical Care Coordinator acknowledged the existence of an order for the brace but confirmed the absence of further documentation or a care plan related to the brace. The facility's policy on the Restorative Nursing Program emphasized evaluating residents individually to maintain their highest functional level, yet there was no evidence of such evaluation or documentation for the resident's hand brace. This lack of documentation and monitoring represents a deficiency in the facility's care for the resident.
Delayed Response to Resident's Change in Mental Status
Penalty
Summary
The facility failed to act timely on a change in mental status for Resident #11, who was observed experiencing visual hallucinations and delusions. On 4/9/2025, the resident reported seeing cats on her dresser, which she described as resembling wolves. This was a new onset for the resident, who had no prior history of delusions or visual hallucinations. Despite the resident's ability to communicate her needs and the presence of a major depressive disorder among her diagnoses, the facility did not address these symptoms promptly. The resident's hallucinations were first noted on 3/31/2025, when a CNA reported the resident talking about seeing live rats, but no immediate action was taken. The delay in addressing the resident's change in condition was further highlighted by the Nurse Practitioner's documentation on 4/1/2025, which noted the resident's confusion and visual hallucinations but did not result in further assessment or monitoring. It was not until the survey process on 4/9/2025 that the facility began to take steps to address the issue, including initiating a behavior log and planning a medical workup. This lack of timely intervention represents a deficiency in the facility's response to a significant change in the resident's mental status.
Failure to Prevent Pressure Ulcers and Conduct Timely Skin Assessments
Penalty
Summary
The facility failed to implement meaningful interventions to prevent the development of a pressure ulcer for Resident #83 and ensure timely skin assessments for Resident #33. Resident #83, who was admitted with multiple diagnoses including a Stage 3 pressure ulcer, was observed to have a worsening condition of her pressure ulcer on the left buttock. Despite being reliant on staff for assistance with turning and repositioning, the facility did not replace her worn wheelchair cushion for over a month, which was a significant factor in the development and progression of her wound. The facility's care plan lacked proactive measures to prevent further skin breakdown, and interventions were only added after the wound had developed. Resident #33, who was admitted with conditions such as dementia and heart failure, had a suspected deep tissue injury on her right heel and ankle. The facility failed to conduct timely skin assessments, as there was a gap between assessments from March 14 to March 28, during which no skin assessment was completed. This oversight was acknowledged by the unit manager, who stated that skin assessments should have been conducted twice weekly in conjunction with shower days. The lack of timely skin assessments contributed to the failure to identify and address skin issues promptly. The facility's policy on skin risk assessment and treatment was not adequately followed, as evidenced by the lack of daily skin inspections and timely reporting of abnormal skin conditions. The deficiencies in both cases highlight a failure to adhere to established protocols for skin care and prevention, leading to the development and progression of pressure ulcers in the residents.
Failure to Follow Enteral Nutrition Orders and Notify DPOA
Penalty
Summary
The facility failed to adhere to a physician's order for enteral nutrition for Resident #95, who was observed with an incorrect infusion rate of 50 mL/hour instead of the prescribed 60 mL/hour. This discrepancy was noted on 4/8/2025, despite the physician's order being updated on 4/1/2025. The nurse responsible for Resident #95 was unaware of the change in the infusion rate, and the error was not corrected until later in the day when the rate was temporarily increased to compensate for the missed volume. Additionally, the facility did not notify Resident #95's Durable Power of Attorney (DPOA) about the change in the tube feed rate from 50 mL/hour to 60 mL/hour. The resident's daughters, who are frequently present at the facility, were not informed of this change or the temporary increase in the infusion rate to make up for the missed volume. This lack of communication with the resident's responsible party was confirmed by both the daughters and the Registered Dietitian. Furthermore, there were no documented orders for the routine cleansing, assessment, and monitoring of Resident #95's PEG tube site following her readmission on 3/21/2025. The Clinical Care Coordinator and Corporate Nurse confirmed the absence of such orders, which are essential for maintaining the site. The facility's policy on medication administration emphasizes resolving any discrepancies before proceeding, yet this was not adhered to in the case of Resident #95.
Failure in Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to operationalize policies and procedures for skin and wound assessments, leading to the development of pressure ulcers in three residents. Resident #1 developed a Stage III pressure ulcer on the coccyx and multiple suspected deep tissue injuries on the feet. The resident was severely cognitively impaired, dependent on staff for repositioning, and had a poor appetite. Despite being on a pressure-relieving mattress, there was a lack of documentation regarding repositioning and the application of protective boots. The care plans lacked specific interventions for each wound, and skin assessments were not conducted consistently. Resident #2 developed a Stage II pressure ulcer on the right buttock and a Stage IV pressure wound on the right ischium. The resident had moderately impaired cognition and was dependent on staff for mobility. The care plan did not include specific positioning guidelines, and wound assessments were not conducted regularly. During a dressing change, infection control protocols were not followed, as the nurse used the same 4x4 gauze to clean multiple wounds without changing gloves or performing hand hygiene. Resident #3's skin assessments were not completed consistently, with gaps of up to 14 days between assessments. The Director of Nursing acknowledged the lack of consistent documentation and indicated that the air mattress settings were incorrect. The facility's policy required weekly skin assessments and documentation of wound characteristics, but these were not adhered to, leading to the deficiencies observed.
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Illustrative
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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 Clio
How nearby facilities compare on the same public inspection record.
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| Medilodge Of Montrose Inc | 6.7 mi | ★★★★★ | 28 | 0 |
| Medilodge Of Frankenmuth | 9.6 mi | ★★★★★ | 5 | 0 |
| Wellspring Lutheran Services | 9.6 mi | ★★★★★ | 17 | 0 |
| Majestic Care Of Flushing | 9.8 mi | ★★★★★ | 6 | 0 |
| Kith Haven | 11.1 mi | ★★★★★ | 15 | 0 |
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