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 Lawn Senior Care during CMS and state inspections, most recent first.
RN coverage was not maintained as required when the facility had no RN on duty for one day reviewed. The DON stated she managed the licensed nurse schedule and confirmed there was no RN coverage on that date, despite the facility policy requiring an RN onsite for 8 consecutive hours per day, 7 days a week.
Unqualified Dietary Manager: The facility failed to designate a qualified person to oversee the dietary department. The designated dietary manager was not certified, had dropped the Dietary Managers Course, had not completed required coursework, and was not enrolled in any program. The RD stated she was available as a preceptor, while the administrator said the position should have been certified or at least enrolled in the course with Serve Safe certification.
A resident with intact cognition, mobility limitations, and multiple chronic diagnoses was not given a care conference after admission, so she did not participate in the development of her person-centered care plan. Record review and staff interviews confirmed no care conference was documented, despite facility policy calling for an interdisciplinary care planning meeting soon after admission and quarterly thereafter.
The facility failed to notify the ombudsman after hospital transfers and discharges for 3 residents. One resident was sent out for poor color, cyanosis, and shaking and later returned after acute hypoxia with respiratory failure; another resident with multiple chronic conditions was hospitalized after a change in condition; and a third resident was discharged home AMA when family took the resident home before a safety evaluation was completed. The SSD said ombudsman notifications had not been completed since 2024, and the DON said she knew of the requirement but was unaware it was not being done.
A resident with intact cognition, mobility limitations, and ADL assistance needs had a care plan that did not include the resident’s anticoagulant therapy or monitoring for side effects. The resident was receiving Apixaban for atrial fibrillation and had a history of stroke, but the care plan only addressed other conditions such as low body mass, HTN, IBS, and gout. The RN confirmed the omission, and the DON stated that residents taking anticoagulants should have interventions and monitoring, including side effects, identified on the care plan.
Failure to update restorative care plan for a resident refusing therapy: A resident with multiple diagnoses, mobility impairment, and a wheelchair-based care profile had a restorative program for exercises and walking, but the record showed declining function, refusal to walk, and no updated assessments or documentation of refusals. The RN and DON acknowledged the care plan should have been revised when the restorative plan changed and when the resident stopped participating, but the chart lacked the required updates and related documentation.
Failure to document and communicate a newly identified skin wound for a resident with DM, dementia, HF, HTN, and prior stroke. The resident said she had a sore on the back of her leg that was kept covered, but the care plan and skin audit did not identify a wound, and progress notes only mentioned a small bandage to the shin. An LPN later found a dated dressing on the calf with no initials and discovered a small open wound with drainage, while the DON stated the nurse should have obtained provider orders, set up treatment, and documented the wound assessment.
Failure to provide planned restorative ROM services: A resident with cerebral palsy, dementia, and impaired lower-extremity mobility was care planned for daily restorative exercise with an arm bike to maintain upper body strength, but staff did not consistently provide the service. The resident said staff did not do ROM exercises, an NA could not recall the last time restorative care was completed, the DON acknowledged gaps in the program, and the assigned aide said the resident was not on her list and she had not done restorative exercises with him.
The facility failed to manage food storage and cleanliness, affecting 37 residents. Expired milk and unlabeled desserts were found, and a fan in the dishwasher room had lint debris, risking contamination of clean dishes. The dietary manager and maintenance supervisor acknowledged these issues, revealing lapses in protocol and maintenance responsibilities.
A facility failed to ensure its narcotic emergency kit did not contain expired medications and that the E-kit contents label was updated monthly. An observation revealed that several medications, including lorazepam and warfarin, had expired. Interviews with the DON and consulting pharmacist supervisor highlighted a lack of clarity regarding the responsibility for updating and reviewing the E-kit medications, leading to the oversight of expired medications.
The facility failed to obtain informed consent for psychotropic medication use for two residents and did not establish a baseline assessment for monitoring abnormal involuntary movements for a resident prescribed a new antipsychotic medication. The Director of Nursing acknowledged the oversight in obtaining consents and completing necessary assessments, and the facility's policy on antipsychotic medication use was not reviewed and updated annually as required.
RN Coverage Not Maintained
Penalty
Summary
The facility failed to ensure a registered nurse (RN) was on duty a minimum of 8 consecutive hours per day, 7 days a week for 1 of 92 days reviewed, affecting all 33 residents. Review of the facility’s November 2025, December 2025, and January 2026 schedules showed that on 11/29/25 there was no RN on duty. During an interview on 2/26/26 at 8:23 a.m., the DON stated she was responsible for the licensed nurse schedule and reported that she worked Monday through Friday for 8 consecutive hours, with another RN covering if she left early, and that on weekends she ensured an RN was scheduled for 8 consecutive hours or she or another facility RN would come in to cover the requirement. She confirmed there had been no RN coverage on 11/29/25. The facility’s undated RN Coverage policy stated the facility would ensure the services of an RN were provided onsite for 8 consecutive hours per day, 7 days a week.
Unqualified Dietary Manager
Penalty
Summary
The facility failed to designate a qualified person to serve as the director of food service to oversee the dietary department. During interview, the designated dietary manager stated she was not certified, had enrolled in a class but dropped it in December because of personal life issues, had not submitted any required coursework, and was not currently enrolled in any program. The registered dietician stated she was the dietary manager's preceptor and available to help with questions and review coursework, but understood the dietary manager was out on medical leave and had dropped the class because she was unable to complete the coursework. The administrator stated she would have expected the dietary manager to be certified for the position, or at minimum enrolled in the class and have a Serve Safe certification to oversee the department and staff. The facility's dietary director job description stated the position required taking or being willing to take the Dietary Managers Course and passing the sanitation test or being willing to take a state-approved course.
Missed Care Conference for Cognitively Intact Resident
Penalty
Summary
The facility failed to ensure a resident participated in the development and implementation of her person-centered plan of care because no care conference was held after admission. The resident had been admitted in mid-November 2025, had intact cognition, used a walker or wheelchair for mobility, required partial assistance with some ADLs, and had diagnoses of arthritis, thyroid disorder, diabetes, renal disease, and hypertension. Her MDS assessments identified that she remained cognitively intact and planned to remain living in the facility. Interview and record review showed the resident stated she had not been invited to or attended any care conference since admission. Her progress notes from 11/12/25 through 2/22/26 contained no mention of a care conference, and her assessments did not include an interdisciplinary care conference or care conference form. Staff interviews confirmed care conferences were typically scheduled within 2 to 4 weeks of admission or 7 to 10 days after completion of the comprehensive MDS assessment, but the resident's initial care conference had been missed and was not scheduled until March, about 4 months after admission. The facility policy stated residents would receive a person-centered comprehensive care plan developed through the interdisciplinary team with the resident and/or representative, and that the care planning meeting would be documented.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to ensure the ombudsman was notified after discharge from the facility for 3 of 3 sampled residents. For one resident, the record showed an unplanned discharge to the hospital after the resident was sent by ambulance for poor color, cyanotic lips, and shaking; the resident was later admitted with acute hypoxia with respiratory failure and returned to the facility, but no ombudsman notice of discharge was provided by the end of the survey period. Another resident had diagnoses including COPD, dementia with moderate mood disturbance, Alzheimer's, CHF, A-fib, hepatic failure, CKD stage 3, anxiety disorder, type II diabetes, HTN, and chronic respiratory failure with hypoxia; after a change in condition and review of laboratory results, the resident was hospitalized, and no documentation was provided showing the ombudsman was notified of the discharge. A third resident was discharged with return not anticipated after the family arrived and reported they were taking the resident home without waiting for the results of the home safety evaluation, and the resident was discharged home Against Medical Advice (AMA). The social services designee stated she had not completed ombudsman notifications since 2024 and was not aware of the requirement to provide notification of hospital admissions or facility discharges. The DON stated she was aware of the regulation for ombudsman notification of hospitalizations and discharges, but was not aware it was not being completed.
Incomplete Care Plan for Anticoagulant Monitoring
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for one sampled resident, R28, who had intact cognition, used a walker or wheelchair for mobility, and required partial to moderate assistance with ADLs. R28’s records showed a diagnosis of persistent atrial fibrillation, high blood pressure, a history of broken wrist, long-term anticoagulant use, and a history of stroke. The resident’s order summary showed Apixaban 2.5 mg twice daily for atrial fibrillation, but there was no order or mention of monitoring for side effects of the anticoagulant medication, including bleeding, nausea, or increased bruising. R28’s September 2025 care plan addressed potential nutritional problems related to low body mass, high blood pressure, atrial fibrillation, irritable bowel syndrome, and gout, but it did not mention the anticoagulant medication or the need for staff to monitor for its side effects. During interview, the RN confirmed the care plan did not include anticoagulant medication or monitoring for side effects and agreed that information should be on the care plan. The DON stated that any resident taking an anticoagulant should have interventions and monitoring identified on the care plan and include the medication’s side effects. The facility policy stated that each resident would have a person-centered care plan with measurable goals, developed or revised within 7 days of completion of the MDS assessment.
Failure to Update Restorative Care Plan for Resident Refusing Therapy
Penalty
Summary
The facility failed to appropriately assess, document, and revise the care plan for a resident whose care plan included restorative therapies that were not being completed as indicated. The resident’s quarterly MDS assessment identified intact cognition, bilateral upper and lower extremity impairments, wheelchair use for mobility, and dependence on staff for dressing, personal hygiene, toileting, bathing, and transfers. The resident had multiple diagnoses, including pulmonary disease, asthma, tremors, lumbar radiculopathy, polyneuropathies, arthritis, high blood pressure, restless leg syndrome, and a functional implant in the back that required charging. The resident’s care plan identified risk for weakness and loss of self-care and mobility independence and included an informal restorative program with dowel exercises, leg exercises, and a walking plan with a four-wheeled walker and restorative aide assistance. However, later functional assessments showed a decline from partial/moderate assistance with transfers and supervision for ambulation to substantial/maximal assistance, then dependence for transfers, and eventually no attempt to walk because of medical conditions or safety concerns. The record did not contain other assessments related to restorative exercise abilities, and progress notes showed the restorative plan was changed to ambulate to breakfast as tolerated without documentation explaining the change or addressing the resident’s inability to walk. Progress notes and interviews showed the resident was having increasing difficulty standing, at times could not stand because his legs buckled, and was weaker and less able to assist with care, but there was no documented nurse assessment of those concerns. The resident reported he did not participate in restorative exercise and said he squeezed a ball instead, while an NA stated he never walked and refused to walk. An LPN stated the resident used to walk but would not walk anymore and often said he was waiting to die; the LPN also noted the resident’s leg issues and back implant could affect his ability to walk. The RN and DON acknowledged the care plan should have been updated when the restorative program changed and when the resident refused to walk, and the record lacked documentation of refusals, updated restorative assessments, or risk-to-benefit information showing the resident was informed of possible decline from not completing restorative treatments.
Failure to Document and Communicate a Newly Identified Skin Wound
Penalty
Summary
The facility failed to re-assess nursing interventions and communicate findings after a skin wound was identified for one resident who had been admitted in mid-February 2026 with heart failure, diabetes, dementia, high blood pressure, and a history of stroke. The resident stated she had a sore on the back of her right leg that the nurse kept covered because she scratched it. Her baseline care plan did not mention wounds or wound risk, and the 2/20/26 weekly skin audit documented bruising on the arm and abdomen but no open lesions, cuts, lacerations, skin tears, blisters, ulcers, or edema. Progress notes from admission through the morning of 2/24/26 documented an initial skin assessment with no open areas and later noted only a small bandage to the right shin for a small broken scab. There was no documentation of a wound on the back of the right leg, no nursing or physician orders for wound treatment or monitoring, and no progress note showing the wound had been communicated for continued monitoring. During observation, an LPN found a self-adhesive padded dressing dated 2/20/26 on the resident’s right calf with no initials, removed it, and found a small open wound with a small amount of drainage. The DON stated the nurse who identified the wound should have contacted the primary provider for orders, set up treatment, and documented a progress note.
Failure to Provide Planned Restorative ROM Services
Penalty
Summary
The facility failed to provide services to maintain and/or prevent a decrease in range of motion for one resident with limited ROM. The resident had cerebral palsy and dementia, was cognitively moderately impaired, was dependent on staff for ADLs, had impairment in both lower extremities, and used a manual wheelchair for mobility. The resident’s care plan identified a risk for decline in physical condition related to cerebral palsy and stated a goal for participation in a restorative exercise program to maintain upper body strength, including daily assistance with an arm bike for 15 minutes with moderate resistance. The resident stated that staff did not do ROM exercises with him. A nursing assistant reported that restorative exercises were sometimes done but that another aide was generally responsible, and she could not recall the last time she had completed restorative care with the resident. The DON stated the facility had recently started having one aide complete some restorative exercises, acknowledged there was a gap, and said it was unlikely the resident’s restorative exercise were being done every day. The aide assigned to light restorative work stated the resident was not on the list she was given and that she had not completed any restorative exercises with him. The administrator stated staff were expected to complete restorative exercises as care planned, and the facility had discussed hiring a restorative aide.
Deficiencies in Food Management and Kitchen Cleanliness
Penalty
Summary
The facility failed to properly manage food storage and cleanliness in the kitchen, which had the potential to affect all 37 residents. During an observation and interview with the dietary manager, it was found that the refrigerator contained expired milk and unlabeled desserts, while a pre-made salad was discolored and past its date. The dietary manager acknowledged these issues and confirmed that the expired and unlabeled items needed to be discarded. Additionally, a fan in the dishwasher room was observed to have lint debris, which could potentially contaminate clean dishes. The dietary manager noted that the maintenance department was responsible for cleaning the fan, but it was not being regularly maintained. Interviews with the dietician and maintenance supervisor revealed further lapses in protocol. The dietician stated that expired food should be discarded within 48 hours past the best use by date and expected all food items to be labeled and dated. The maintenance supervisor admitted that the fan was only cleaned as needed and was surprised by its condition, indicating a lack of regular cleaning. The director of nursing expected the kitchen staff to monitor for expired food and maintain cleanliness, including the fan. However, the dietary shift cleaning checklist did not include the fan, and there was no policy provided for monitoring expired food or ensuring items were labeled and dated.
Expired Medications Found in Narcotic Emergency Kit
Penalty
Summary
The facility failed to ensure that one of its two narcotic emergency kits (E-kits) did not contain expired medications and that the E-kit contents label was updated monthly and current. During an observation, a large narcotic E-kit was identified with a red numbered tag, indicating it had not been opened. However, upon review, it was found that several medications within the E-kit, including lorazepam, warfarin, sulfamethoxazole/trimethoprim, doxycycline, levofloxacin, and prednisone, had expired on 12/15/24. The E-kit medication log from July 2023 also showed discrepancies, such as missing expiration dates and outdated information. Interviews with the Director of Nursing (DON) and the consulting pharmacist supervisor revealed a lack of clarity and communication regarding the responsibility for updating and reviewing the E-kit medications. The DON was aware that the local pharmacy was supposed to replace E-kit medications monthly and upon request, but there was uncertainty about whether the clinical pharmacist had a process to review the E-kit medications. The consulting pharmacist supervisor stated that the E-kit was the pharmacy's responsibility and expected the facility to have an updated E-kit medication log. However, the facility had not received an updated medication log for the current year, leading to the oversight of expired medications in the E-kit.
Failure to Obtain Informed Consent and Conduct Baseline Assessments for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the use of psychotropic medications for two residents, R32 and R91. R32, who had severe cognitive impairment and was dependent for all care, was prescribed Depakote and Zoloft for anxiety and depression. However, there was no documentation of consent from the resident, family, or guardian for these medications. Similarly, R91, who had moderate cognitive impairment and was on hospice care, was prescribed Zoloft, Zyprexa, Buspirone, and Ativan for anxiety and depression. Again, there was no indication of consent for these medications in the medical record. Additionally, the facility failed to establish a baseline assessment for monitoring abnormal involuntary movements for R91, who was prescribed a new antipsychotic medication, Zyprexa. The Director of Nursing (DON) acknowledged that the assessment for involuntary movements was supposed to be completed when a resident started on an antipsychotic medication, but this was not done for R91. The consulting pharmacist also confirmed the expectation for a baseline assessment upon starting an antipsychotic medication. The DON admitted to forgetting about obtaining consents for psychotropic medication use and completing the necessary assessments following R91's new antipsychotic medication order. The facility's policy required an AIMS assessment at the start of an antipsychotic medication and quarterly thereafter, but there was no indication that this policy had been reviewed and updated annually as required by regulation.
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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 Fulda
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - Westbrook | 14.1 mi | ★★★★★ | 11 | 0 |
| The Shores Of Worthington | 18.3 mi | ★★★★★ | 21 | 1 |
| Good Samaritan Society - Windom | 23.6 mi | ★★★★★ | 23 | 1 |
| Prairie View Senior Living | 24.7 mi | ★★★★★ | 6 | 0 |
| Colonial Manor Nursing Home | 25 mi | ★★★★★ | 21 | 0 |
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