Above 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 Maplecrest Nursing And Hta during CMS and state inspections, most recent first.
A resident with multiple health conditions and high risk for pressure ulcers developed an in-house acquired unstageable pressure ulcer due to the facility's failure to implement and document individualized prevention interventions, incomplete and inconsistent wound assessments, and improper infection control practices during wound care. Staff did not communicate or document care refusals, and wound care was performed in a manner that risked cross-contamination between wounds.
A resident with impaired cognition and multiple medical conditions had discrepancies between their advance directive documentation, care plan, and physician orders. The care plan listed the resident as full code, while the most recent DNR Comfort Care form indicated DNR comfort care, and the physician order reflected DNR comfort care-arrest. Both an LPN and the DON confirmed these inconsistencies, which were not in accordance with facility policy.
A resident with a PICC line for IV antibiotics did not have their dressing changed or documented as ordered for a two-week period. Observation revealed the dressing was loose and peeling, and an LPN admitted to signing off on the dressing change without actually performing it. Facility policy and physician orders required weekly dressing changes and documentation, which were not followed.
A resident with multiple complex diagnoses was receiving psychoactive medications, and the facility's pharmacist recommended a dose reduction for Risperidone. The physician did not respond to this recommendation for several weeks, despite regular visits from both the psychiatrist and nurse practitioner. This delay was confirmed by the DON and was not in accordance with facility policy requiring timely review and response to pharmacy recommendations.
A resident with dysphagia and cognitive impairment, who was ordered a puree diet with honey thick liquids due to aspiration risk, was observed receiving minced/chopped food instead of the required smooth, lump-free puree. Staff interviews and documentation confirmed the food texture did not meet the physician and speech therapy orders.
A nurse failed to follow proper infection control procedures while providing wound care to a resident with multiple pressure ulcers, including one with a known infection. The nurse did not perform hand hygiene or change gloves between treating separate wounds, using the same gloved hands and supplies for both areas, which was confirmed by both the nurse and the DON as improper and potentially leading to cross-contamination.
Six residents were found to be living in single rooms that did not meet the minimum required 100 square feet of living space, with room sizes ranging from 91.50 to 97.75 square feet, as confirmed by facility records and administrator interview.
A resident developed a stage II pressure ulcer under a hinged brace due to the facility's failure to regularly assess the skin. The resident, with a history of a femur fracture and other conditions, was admitted without pressure ulcers but was at risk. Despite a care plan for skin assessments, no documentation was made until the ulcer was found. The ulcer was discovered by an STNA after the resident complained of pain, and treatment orders were delayed until two days later.
Failure to Implement Comprehensive Pressure Ulcer Prevention and Proper Wound Care
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program for a resident who was at high risk for pressure ulcers due to multiple factors, including impaired cognition, dependence on staff for most activities of daily living, and limited mobility. The resident was admitted with several diagnoses, including acute kidney failure, hypertension, osteoarthritis, and muscle wasting with atrophy. The care plan identified the resident as being at risk for impaired skin integrity and included interventions such as regular skin assessments, turning and repositioning every two hours, incontinence care, and the use of pressure-relieving devices. However, documentation revealed that these interventions were not effectively implemented or monitored, as evidenced by the development of an in-house acquired unstageable pressure ulcer to the right gluteal fold. Nursing documentation and wound assessments were inconsistent and incomplete. A new area was noted on the resident's right gluteal fold, but there was no staging, description, or measurement documented at the time of discovery. The wound was later assessed as unstageable with 90% slough, and it was incorrectly documented as present on admission. Interviews with nursing staff revealed a lack of communication regarding the resident's care needs, including an instance where the resident refused to turn, which was not communicated or documented in the care plan. The Minimum Data Set (MDS) assessment was also marked incorrectly, indicating that turning and transfers were not attempted due to a medical condition, despite there being no such condition preventing these interventions. Infection control practices during wound care were not followed according to facility policy. During an observed dressing change, the wound nurse failed to perform hand hygiene between handling two separate wounds, used the same gloved hands and supplies for both wounds, and did not change gloves or wash hands after removing old dressings. This created a potential for cross-contamination, especially since one of the wounds was known to be infected. The facility's policies on pressure injury prevention and wound care were not adequately followed, and there was no specific guidance for managing multiple wounds during dressing changes.
Failure to Accurately Document and Update Advance Directives
Penalty
Summary
The facility failed to ensure that a resident's advance directives were accurately reflected in both the physician orders and the care plan. The resident, who had diagnoses including acute kidney failure, hypertension, osteoarthritis, and muscle wasting with atrophy, was admitted with impaired cognition. The care plan dated 12/10/24 indicated the resident was a full code, while a DNR Comfort Care form signed by the primary care physician on 12/26/24 indicated the resident was to be DNR comfort care. However, the physician order in the electronic medical record, dated 12/27/24, still listed the resident as DNR comfort care-arrest, which did not match the most recent DNR Comfort Care form. Interviews with both an LPN/MDS nurse and the DON confirmed that the care plan and physician orders were inaccurate and did not reflect the resident's current advance directive status. The facility's policy required that any changes to advance directives be communicated to the care plan team and documented appropriately, but this process was not followed, resulting in discrepancies between the resident's documented wishes and the orders in the medical record and care plan.
Failure to Change and Document PICC Line Dressing as Ordered
Penalty
Summary
Resident #43, who had diagnoses including acute kidney failure, hypertension, osteoarthritis, and muscle wasting with atrophy, was admitted with a peripherally inserted central catheter (PICC) line for intravenous (IV) therapy, including antibiotics. Physician orders and the resident's care plan required weekly PICC line dressing changes and monitoring for signs of infection or infiltration. Review of the Treatment Administration Record (TAR) showed that the dressing change was not documented as completed for a two-week period, specifically from 03/13/25 to 03/27/25, and there was no documentation that the dressing was changed as ordered on 03/20/25. On observation, the PICC line dressing was found to be loose and peeling, and the date on the dressing indicated it had not been changed as scheduled. An LPN confirmed that she had signed off in the TAR that the dressing was changed, but admitted she had not actually performed the dressing change. The Director of Nursing verified that PICC line dressings were to be changed weekly and that this resident was the only one receiving IV therapy. Facility policy also required dressings to be changed every seven days or sooner if loose, and for nurses to document the procedure and site condition.
Delayed Physician Response to Pharmacy Medication Recommendation
Penalty
Summary
The facility failed to ensure that pharmacy recommendations regarding a resident's medication regimen were reviewed and responded to in a timely manner by the physician. Specifically, a resident with diagnoses including cerebral infarction, schizoaffective disorder, major depression, hemiplegia, anxiety disorder, and chronic pain syndrome was receiving multiple medications, including antipsychotic and antidepressant drugs. The pharmacy made a recommendation for a dose reduction of Risperidone, a psychoactive medication, on 02/18/25. However, there was no documentation of a physician response to this recommendation until 04/07/25, when the physician indicated not to reduce the medication. Review of the resident's medical record, treatment records, progress notes, and physician orders confirmed the delay in response. The DON verified that the recommendation was made and acknowledged the response was not timely, despite the psychiatrist visiting every six weeks and the nurse practitioner being present more frequently. Facility policy required staff and practitioners to seek appropriate dosing and duration for each medication to minimize adverse consequences, but this process was not followed in this instance.
Failure to Provide Physician-Ordered Puree Diet Texture
Penalty
Summary
A deficiency occurred when the facility failed to provide a resident with food prepared in the physician-ordered texture, specifically a puree diet with honey thick liquids. The resident, who had diagnoses including dysphagia, chronic kidney disease, and cognitive communication deficit, was assessed as being at high risk for aspiration and required a puree diet and honey thick liquids as per physician and speech therapy orders. The care plan and medical record indicated the need for close monitoring and supervision during meals, with interventions to prevent aspiration. During observation, the resident was served breakfast items that were of minced/chopped consistency rather than smooth and lump-free puree, as required. Both the DON and Dietary Manager confirmed that the food provided did not meet the ordered puree texture. The speech therapist and registered dietitian also verified that the resident was to receive only puree consistency foods and honey thick liquids due to the risk of aspiration. The facility's policy defined puree as smooth and lump-free, which was not followed in this instance.
Failure to Follow Infection Control Practices During Wound Care
Penalty
Summary
A deficiency was identified when a registered nurse (RN) failed to follow appropriate infection control practices during wound care for a resident with multiple pressure ulcers. The resident had a history of acute kidney failure, hypertension, osteoarthritis, muscle wasting, and was at risk for impaired skin integrity. The care plan included regular skin assessments, repositioning, and wound treatments as ordered. The resident had two significant wounds: a coccyx pressure ulcer, which had been cultured and found to be infected, and a right gluteal fold wound, both requiring specific dressing changes and infection control measures. During an observed wound care procedure, the RN performed hand hygiene and donned personal protective equipment before removing the dressings from both wounds. However, after removing the old dressings, the RN changed gloves but did not wash her hands. She then cleansed, packed, and dressed both wounds consecutively using the same gloved hands, including using unsterile and sterile gauze on both wounds without changing gloves or performing hand hygiene between wounds. The RN also applied skin prep and dressings to both wounds with the same gloved hands, despite one wound being known to be infected. This process was confirmed by both the RN and the Director of Nursing (DON) as improper and having the potential for cross-contamination between wounds. The facility's wound care policy required hand hygiene after removing old dressings and before applying new gloves, but did not specify procedures for multiple wounds. The RN and DON acknowledged that the failure to change gloves and perform hand hygiene between treating separate wounds, especially when one was infected, could lead to cross-contamination. The observation and interviews confirmed that infection control protocols were not followed during the wound care process for this resident.
Single Resident Rooms Below Required Square Footage
Penalty
Summary
The facility failed to provide single resident rooms with at least 100 square feet of living space, as required. During a survey, it was confirmed through interview with the Administrator and review of the space/occupancy certification waiver that six single rooms, each occupied by a resident, measured less than the required 100 square feet. The specific room sizes ranged from 91.50 to 97.75 square feet. This deficiency affected six residents who were residing in these undersized single rooms at the time of the survey.
Failure to Assess Skin Under Brace Leads to Pressure Ulcer
Penalty
Summary
The facility failed to properly assess the skin condition of a resident who was wearing a right lower extremity hinged brace, resulting in the development of an in-house acquired stage II pressure ulcer. The resident, who had a history of a displaced comminuted fracture of the right femur, chronic atrial fibrillation, and cerebral infarction, was admitted without any pressure ulcers but was at risk for skin breakdown. Despite having a care plan that included weekly skin assessments and repositioning every two hours, the facility did not document any skin assessments under the brace until a pressure ulcer was discovered on the resident's right lower extremity on 05/18/24. The pressure ulcer was identified by a state tested nurse aide (STNA) who noticed the resident's complaint of pain and found the ulcer under the brace. There was a delay in implementing treatment orders, as they were not documented until 05/20/24. The wound was described as a stage II pressure ulcer with partial thickness loss of dermis, and it was attributed to the hinged brace. The facility's failure to assess the skin under the brace regularly led to the development of the ulcer, which was confirmed by the wound care registered nurse upon her return to work.
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Struthers
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Center Healthcare And Rehabilitation | 1.8 mi | ★★★★★ | 18 | 0 |
| Lincoln Knolls Health & Rehab Llc | 3 mi | ★★★★★ | 26 | 0 |
| Oasis Center For Rehabilitation And Healing | 3 mi | ★★★★★ | 16 | 0 |
| Beeghly Oaks Center For Rehabilitation & Healing | 3.3 mi | ★★★★★ | 0 | 0 |
| Greenbriar Center | 3.7 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.