Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Greens At Maple Leaf during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and limited mobility fell from bed during incontinence care after misunderstanding a nurse aide's instruction, resulting in a hip fracture, femur fracture, and scalp hematoma. The aide was unable to prevent the fall as her hands were occupied, and the resident moved quickly. The incident occurred while the resident was assessed as a one-person assist for bed mobility and did not have bed rails.
Surveyors found two medication carts with numerous loose, unsecured pills and observed that DuoNeb inhalation vials were not stored in their original foil packaging or dated as required. Medication Aides and nursing staff demonstrated inconsistent understanding and execution of responsibilities for maintaining clean, orderly carts and proper medication storage, as confirmed by interviews with the Unit Manager and DON.
Two residents had errors in their MDS assessments: one was not coded for receiving anticonvulsant and hypoglycemic medications despite documented administration, and another was incorrectly coded as receiving an anticoagulant when none was prescribed or given. MDS nurses acknowledged the miscoding during interviews.
A resident admitted with multiple mental health diagnoses and prescribed antipsychotic and antidepressant medications did not have a required PASRR reevaluation submitted, as the process was overlooked by staff following an audit completed prior to the resident's admission.
A resident sustained a skin tear and bruise after a nurse aide ignored his requests to let go of his arm during incontinent care. The incident was not documented in the medical record, and the facility's staff provided inconsistent accounts of the event. The facility failed to protect the resident from potential abuse and ensure accurate medical documentation.
A resident with severe cognitive impairment exited the facility unsupervised through an unlocked door. The resident was found in the parking lot and brought back inside without injury. The door had been left unlocked after a delivery earlier in the day, and no staff heard the alarm. The resident's care plan was updated, and a wander guard bracelet was applied.
A resident reported that a nurse aide grabbed his arm too tightly, causing a bruise and skin tear. The incident was not documented or reported immediately, and the facility failed to follow its abuse policy and procedures, leading to a delay in investigation and protection of the resident.
The facility failed to remove expired medications from a medication refrigerator. Two open vials of PPD solutions were found with open dates exceeding the 30-day usage limit. Interviews revealed that neither the Unit Manager nor the Nurse were aware of the 30-day limit, and the Unit Manager had not identified the expired solutions during a previous inspection.
The facility's QAA committee failed to maintain procedures and monitor interventions, resulting in repeat deficiencies in abuse prevention and infection control. A resident was injured during incontinent care, and another resident was attacked by a cognitively impaired peer. Additionally, staff failed to follow infection control policies, such as changing gloves and performing hand hygiene.
The facility failed to follow infection control and hand hygiene policies during wound care and incontinent care for two residents. The Wound Nurse did not change gloves after removing a soiled dressing, and the Unit Manager did not change gloves or perform hand hygiene after cleaning a resident's soiled buttocks and before applying a moisture barrier cream.
Resident Fall During Incontinence Care Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and limited mobility rolled out of bed and fell during incontinence care, resulting in significant injuries. The resident, who had diagnoses including coronary artery disease and dementia with agitation, required substantial assistance for bed mobility and positioning. At the time of the incident, the resident was being assisted by a nurse aide who asked her to roll over during care. The resident misunderstood the instruction and rolled in the opposite direction, falling off the bed onto the floor. The nurse aide reported that she was unable to prevent the fall because her hands were occupied holding a brief and pad, and the resident moved quickly. Following the fall, the resident was found on the floor with a bleeding scalp hematoma and a left leg that appeared shorter than the right. The nurse practitioner and nursing staff assessed the resident, who was subsequently sent to the emergency department. Medical evaluation revealed a non-displaced left hip fracture, a distal left femur fracture, and a scalp hematoma. The resident was treated with pain medication and a knee immobilizer, and her family opted against surgical intervention. The resident's care plan prior to the incident indicated she was a one-person assist for bed mobility, and she did not have bed rails on her bed. Interviews with staff indicated that the resident was considered able to roll herself and hold onto the bed during care, but confusion led to her rolling in the wrong direction. The nurse aide involved stated she did not anticipate the resident's action and could not intervene in time. The incident highlighted a failure to provide adequate supervision and ensure a safe environment during bed mobility and incontinence care for a resident at risk due to cognitive impairment and physical limitations.
Unsecured Medications and Improper Storage of DuoNeb Solution
Penalty
Summary
Surveyors observed that two medication carts (100 and 200 Hall) contained numerous loose and unsecured pills of various shapes, sizes, and colors in the bottom drawers. Medication Aides interviewed during the observations acknowledged that it was their responsibility to keep the carts clean and orderly, but there was inconsistency in their understanding and execution of this duty. The Unit Manager and DON also confirmed that maintaining clean and orderly medication carts was expected of the staff, with the DON noting that an extra nurse had been assigned to clean the carts during a recent shift. Additionally, the 200 Hall medication cart was found to have five DuoNeb inhalation vials stored loosely in a plastic cup, not in their original foil packaging, and without any indication of the date they were removed from the foil pack. Manufacturer guidelines require that DuoNeb vials be stored in the foil pouch to protect from light and be used within seven days of opening. Staff interviews revealed a lack of knowledge regarding proper storage and labeling of the DuoNeb solution, with both the nurse and Unit Manager stating that the vials should be dated and kept in the foil pouch, but this was not being done.
Inaccurate MDS Coding for Medication Administration
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents. For one resident with a history of diabetes mellitus, physician orders and the Medication Administration Record confirmed the administration of gabapentin for diabetic neuropathy and metformin for diabetes. However, the resident's quarterly MDS assessment was not coded to reflect the use of an anticonvulsant or a hypoglycemic medication. The MDS nurse acknowledged the miscoding during an interview and could not provide a reason for the error. In another case, a resident with atrial fibrillation was not prescribed or administered any anticoagulant medication, as confirmed by physician orders and the Medication Administration Record. Despite this, the resident's quarterly MDS assessment was incorrectly coded as receiving an anticoagulant. The responsible MDS nurse admitted to the coding error during an interview. In both instances, the facility administrator stated an expectation for accurate completion of MDS assessments.
Failure to Submit PASRR Reevaluation for Resident with Mental Health Disorders
Penalty
Summary
The facility failed to submit a request for an updated Preadmission Screening and Resident Review (PASRR) evaluation for a resident who was admitted with mental health disorders. The resident had a Level I PASRR determination with no expiration date and was admitted with diagnoses including bipolar disorder, anxiety disorder, and dementia without behavioral disturbance, as well as psychotic and mood disturbances. The resident's medical record showed active physician orders for antipsychotic and antidepressant medications, and the admission Minimum Data Set (MDS) assessment indicated the resident was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. Despite ongoing use of psychotropic medications, there was no evidence that a PASRR reevaluation request had been submitted or completed since the initial Level I determination. Interviews with facility staff revealed that the social worker was responsible for submitting PASRR reevaluation requests but was not always informed when residents with mental health diagnoses were admitted. The administrator confirmed that a PASRR audit had been completed prior to the resident's admission, and the need for a reevaluation for this resident was overlooked because the admission occurred after the audit. As a result, the required PASRR reevaluation was not requested for the resident with significant mental health diagnoses and ongoing psychotropic medication use.
Failure to Protect Resident from Abuse During Incontinent Care
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse when a nurse aide (NA) ignored Resident #17's repeated requests to let go of his arm during incontinent care. Despite the resident's complaints of pain, the NA continued to hold his arm, resulting in the resident pulling his arm away and sustaining a small skin tear with a red/purple bruise on his right forearm. The incident occurred during the night when the NA was alone in the room with the resident, contrary to the usual practice of having two staff members present for such care. Resident #17, who was cognitively intact and had a history of verbal behaviors, reported that the NA laughed at him when he complained about the pain. The resident's medical record revealed no documentation of the incident, the bruise, or the skin tear, and there was no order for treatment of the skin tear. The nurse on duty cleaned the area and applied a dressing but did not complete an incident report or document the change in the resident's condition. Interviews with the NA, nurses, and administrative staff revealed inconsistencies in the accounts of the incident. The NA initially stated she grabbed the resident's elbow but later denied it, claiming she only held his shoulder and hip. The Director of Nursing (DON) and the Administrator were unaware of the incident until later and did not initially identify it as abuse. The facility's failure to document the incident and properly investigate it highlights a significant deficiency in protecting residents from potential abuse and ensuring accurate medical records.
Resident Elopement Due to Unlocked Exit Door
Penalty
Summary
The facility failed to prevent a resident with severe cognitive impairment from exiting the facility unsupervised and without the knowledge of the staff. On the evening of 04/23/24, a nurse aide observed the resident in the back parking lot, approximately 30 yards away from the exit door, holding a plastic bag with her clothes. The resident was redirected back into the facility by the nurse aide, and it was later determined that the resident had exited through an unlocked door at the end of the 400 hall, which was the hall the resident resided on. The door had been left unlocked after a delivery earlier that day, and no staff admitted to hearing the alarm that should have sounded when the door was opened. The resident was assessed for injuries and none were found. The resident, who had a history of coronary artery disease, hypertension, atrial fibrillation, and cerebral vascular accident (CVA), was admitted to the facility with severely impaired cognition. The resident was known to ambulate independently with a walker and had not previously exhibited wandering behaviors. On the day of the incident, the resident had to be redirected multiple times back to her room. The nurse aide assigned to the resident's hall was working a different shift than usual and was not familiar with the resident's behaviors. After the incident, the resident was found to be carrying a water pitcher and a bag of clothes and was wearing a sweat outfit. The resident was brought back inside the facility, and a full body skin assessment was conducted, revealing no injuries. Interviews with staff revealed that the exit door at the end of the 400 hall was unlocked, and the power to the door was turned off. The maintenance supervisor had unlocked the door for a delivery earlier in the day and insisted that he had locked it afterward. However, the door was found to be unlocked during the investigation. The facility conducted a resident head count and checked all exit doors to ensure they were locked and alarming properly. The resident's care plan was updated, and a wander guard bracelet was applied to the resident to prevent future elopements.
Failure to Identify and Report Potential Abuse
Penalty
Summary
The facility failed to identify and report an incident of potential abuse involving Resident #17. The resident, who was cognitively intact and required extensive assistance for bed mobility, reported that a nurse aide (NA #1) had grabbed his arm too tightly while attempting to turn him, resulting in a bruise and a small skin tear. Despite the resident's complaint and visible injury, the incident was not documented in the medical record, and the appropriate reporting and investigative procedures were not initiated immediately as required by the facility's abuse and neglect protocol. Nurse #1, who attended to the resident's injury, did not complete an incident report, mistakenly believing that another nurse (Nurse #3) had done so. The Director of Nursing (DON) later discovered the lapse and instructed Nurse #1 to complete the necessary documentation. The DON and the Administrator both interviewed the involved staff and the resident, but initially did not consider the incident as potential abuse, attributing the injury to the resident's own actions during the turning process. The facility's failure to follow its abuse policy and procedures, including immediate reporting, documentation, and suspension of the accused staff member, was evident. The Administrator and DON only initiated the investigative process after being prompted by the surveyors, highlighting a significant delay in addressing the potential abuse incident. This delay and lack of proper documentation and reporting compromised the facility's ability to protect the resident and ensure a thorough investigation in a timely manner.
Expired Medications in Medication Refrigerator
Penalty
Summary
The facility failed to remove expired medications from a medication refrigerator in the medication room. During an observation, two open vials of Purified Protein Derivative (PPD) solutions were found with open dates of 04/01/24 and 04/03/24, exceeding the manufacturer's recommendation of discarding PPD vials after 30 days due to possible oxidation and degradation. Interviews with the Unit Manager and Nurse revealed that neither was aware of the 30-day usage limit for PPD solutions. The Unit Manager had inspected the refrigerator the previous evening but did not identify any out-of-date PPD solutions. The Director of Nursing was informed of the findings and confirmed the oversight.
Repeat Deficiencies in Abuse Prevention and Infection Control
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions following the Recertification and Complaint Survey. This failure resulted in repeat deficiencies in the areas of abuse and neglect (F600) and infection control (F880). Specifically, a resident's right to be free from abuse was violated when a nurse aide did not release the resident's arm during incontinent care, leading to a skin tear and bruise. Additionally, the facility failed to prevent a cognitively impaired resident from attacking another resident, resulting in injuries that required emergency room evaluation and treatment. The facility also failed to adhere to infection control policies. The Wound Nurse did not change gloves after removing a soiled dressing and before cleansing a sacral wound, and the Unit Manager did not perform hand hygiene after providing incontinent care and before applying a moisture barrier cream. These actions were observed during the current Recertification and Complaint Survey, mirroring similar deficiencies cited in the previous survey. The Administrator, who was not in position during the last survey, considered the current citations to be isolated issues rather than systemic failures.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to follow their infection control policy when the Wound Nurse did not change her gloves after removing a soiled dressing from a resident's sacral wound. The Wound Nurse proceeded to cleanse the stage 3 sacral wound with the same gloves, which were contaminated with brown drainage. This action was observed during a wound care procedure, and the Wound Nurse later admitted that she did not realize her mistake due to nervousness from being observed. The Director of Nursing was informed of the incident and acknowledged the need for the Wound Nurse to be more careful in following proper procedures. Additionally, the facility did not adhere to their hand hygiene policy during the provision of incontinent care for another resident. The Unit Manager failed to change her gloves and perform hand hygiene after cleaning the resident's soiled buttocks and before applying a moisture barrier cream. The Unit Manager also touched other environmental surfaces with the same gloves. This lapse in protocol was observed during a continuous observation period, and the Unit Manager later admitted to forgetting to change her gloves and perform hand hygiene. Interviews with the Infection Preventionist and the Director of Nursing confirmed that staff are expected to perform hand hygiene before and after providing care to prevent contamination. The Director of Nursing stated that the Unit Manager was nervous during the observed procedure and immediately recognized her mistake. The Director of Nursing reeducated the Unit Manager on the hand hygiene policy and initiated reeducation for all staff members.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 81 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Statesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Care Of Statesville | 1.2 mi | ★★★★★ | 2 | 0 |
| Iredell Memorial Hospital Inc | 2 mi | ★★★★★ | 1 | 0 |
| Davie Nursing And Rehabilitation Center | 15.8 mi | ★★★★★ | 3 | 0 |
| Crestview Health & Rehabilitation | 16.3 mi | ★★★★★ | 9 | 0 |
| Glenwood Health & Rehabilitation | 16.8 mi | ★★★★★ | 0 | 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 August 2026) and official state health department websites.