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 Grove Nursing & Rehab Center during CMS and state inspections, most recent first.
A resident with severe cognitive and physical impairments was found during staff rounds with multiple scratches and lacerations on the left lower leg caused by a mouse present in the bed. Staff observed mouse feces and urine, and the resident required transfer to the ER for wound care, antibiotics, tetanus, and rabies vaccinations. Despite prior pest control measures, the rodent gained access to the resident's room, resulting in harm and a failure to maintain a safe, clean, and homelike environment.
Facility staff failed to securely store medications, as observed during a survey. An LPN left a medication cart unattended with DuoNeb, and an RN left Miramax unattended on a cart. Both incidents violated the facility's medication storage policy, which requires drugs to be stored in locked compartments or under direct observation during medication passes.
The facility staff failed to properly dispose of garbage and waste, resulting in a large pile of debris beside the dumpster. The debris included computer screens, keyboards, wooden pallets, wet decorative hay, outdated chicken noodle soup, nightstands, drinking straws, medication cups, drinking cups, and surgical masks. The dumpster was too full to accommodate the debris, and an employee noted that it had been emptied earlier but the debris was not collected. The Administrator stated that the dumpster had been replaced with a smaller one and plans were in place to switch back to a larger size.
The facility failed to follow its policy for screening new employees, specifically for a new Medical Director. The required background and reference checks were missing from the employee's record, and the license on file was expired. Although a current license and a background check were eventually provided, the facility did not initially have the necessary documentation, leading to a deficiency.
The facility staff failed to ensure accurate MDS assessments for three residents, leading to documentation errors regarding dialysis status, discharge location, and catheter use. One resident's dialysis status was not coded, another was incorrectly documented as discharged to a hospital, and a third was inaccurately recorded as having an indwelling catheter. These errors were identified through staff interviews and clinical record reviews.
A resident with severe cognitive impairment and multiple diagnoses, including lactose intolerance, did not have a comprehensive dietary care plan reflecting their dietary needs. Despite the resident's daughter informing the facility of the lactose intolerance, milk continued to be provided. Interviews revealed confusion among staff about who was responsible for updating care plans, contributing to the deficiency.
A resident's care plan was not updated to reflect the removal of an indwelling catheter, which had been discontinued months prior. Despite the resident's severe cognitive impairment and multiple diagnoses, the care plan still indicated the need for a catheter. This oversight was confirmed by an LPN and discussed with facility staff, but no care plan policy was provided to surveyors.
A resident with COPD and other health issues was observed using oxygen at 4 LPM without a physician's order. The resident believed they were receiving 2 LPM and used oxygen continuously. Facility staff were uncertain about the order, and a review showed an order for 2 LPM as needed, but not for continuous use at 4 LPM. The facility's policy requires a physician's order for oxygen administration.
Facility staff failed to properly disinfect glucometers between residents, using alcohol prep pads instead of EPA-registered disinfectant wipes as per the manufacturer's instructions and facility policy. An LPN and the Assistant Director of Nursing confirmed this practice, which was reportedly a carryover from COVID-19 protocols. The issue was discussed with the DON and other administrators, but no additional information was provided before the exit conference.
Resident Injured by Rodent in Bed Due to Environmental Deficiency
Penalty
Summary
Facility staff failed to provide a safe, clean, and homelike environment for a resident, resulting in the presence of a mouse in the resident's bed. The resident, who had significant medical conditions including hemiplegia, hemiparesis, atrial fibrillation, weakness, chronic kidney disease, and severe cognitive impairment, was found during staff rounds with multiple open areas and scratches on the left lower leg. Staff observed a mouse in the bed, along with mouse feces and urine, and noted that the mouse had been gnawing on the resident's leg. The resident was unable to feel pain on the affected side due to her medical history. The incident led to the resident being transferred to the emergency room for evaluation and treatment. Medical documentation confirmed multiple superficial lacerations and excoriations on the left calf, and the resident received wound care, antibiotics, a tetanus vaccine, and a series of rabies vaccinations. Staff interviews corroborated the presence of the mouse in the resident's bed and the resulting injuries. Witness statements described the discovery of the mouse actively biting the resident and the subsequent efforts to capture and dispose of the rodent. Prior to the incident, pest control services had been engaged for rodent prevention, with bait stations and glue boards placed in problem areas. However, the mouse was still able to access the resident's room and bed, resulting in direct harm. Staff and pest control were unable to determine the exact point of entry for the mouse. Observations and interviews conducted during the survey did not reveal ongoing rodent activity, but the documented event demonstrated a failure to maintain a safe and clean environment for the resident.
Medication Storage Deficiency Observed
Penalty
Summary
The facility staff failed to ensure the safe and secure storage of medications and biologicals, as observed during a survey. During a medication pass, an LPN left a medication cart unattended with a vial of DuoNeb, an inhaled liquid medication, while they went to the medication room to retrieve another medication. This incident occurred on the A hall, leaving the medication unsecured and unattended. In a separate observation, an RN left a cup of Miramax, a powdered laxative mixed with water, unattended on the medication cart while they also went to the medication room to find another medication. When questioned, the RN was unsure of the correct procedure. The facility's policy on medication storage, revised in August 2024, clearly states that all drugs and biologicals must be stored in locked compartments and under direct observation during medication passes. These incidents were discussed with the Director of Nursing, Administrator, and Regional Director of Clinical Services, but no further information was provided to the survey team before the exit conference.
Improper Disposal and Containment of Facility Waste
Penalty
Summary
The facility staff failed to ensure proper disposal and containment of garbage and waste. During an observation, a surveyor noted a large pile of debris beside the facility's dumpster, which included computer screens, keyboards, wooden pallets, wet decorative hay, outdated chicken noodle soup, nightstands, drinking straws, medication cups, drinking cups, and surgical masks. The dumpster doors were shut, but the debris was left outside because the dumpster was too full. An employee mentioned that the dumpster had been emptied earlier that day, but the debris was not picked up. The facility's Administrator explained that the dumpster had been replaced with a smaller one due to holes in the previous dumpster, and plans were in place to switch back to a larger size after a concrete pad was poured.
Failure to Follow Employee Screening Procedures
Penalty
Summary
The facility staff failed to adhere to their policy and procedures for screening new employees, specifically for new employee #15, who was identified as the Medical Director. The facility's policy requires potential employees to be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property, which includes conducting background, reference, and credentials checks. However, during the employee record review, it was found that new employee #15's record did not include a criminal background check or reference checks, and the license in the employee file was expired. Although the facility staff were able to provide a current license, they were unable to provide evidence of the required screenings at the time of the survey. The Administrator explained that when new employee #15 was hired, they were licensed in the Commonwealth of Virginia, and a background check and fingerprints had been completed and accepted by the previous company. The facility was in the process of merging with another company, which was completing background checks. Prior to the exit conference, the Administrator provided a sworn statement and a copy of a Virginia State Police Background check indicating no identifiable records. Despite these efforts, the facility failed to provide timely documentation of the required screenings for new employee #15, leading to the deficiency noted by the surveyors.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility staff failed to ensure accurate Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in the documentation of their medical conditions and treatments. For one resident with end-stage renal disease, the staff did not code the resident's dialysis status on the annual MDS assessment, despite the resident's comprehensive care plan and clinical records indicating a need for hemodialysis. This oversight was discovered when the resident was identified as being out of the building for dialysis treatment. Another resident's discharge MDS assessment was inaccurately coded to indicate discharge to a short-term general hospital, while the clinical record showed the resident was discharged home. This discrepancy was noted during a review meeting with facility administrators and clinical directors. Additionally, the facility staff incorrectly coded a resident as having an indwelling catheter on the MDS assessment, even though the catheter had been discontinued prior to the assessment date. The resident's clinical records and a nurse's confirmation indicated that the catheter had been removed, yet the MDS still reflected its presence. This error was identified during an observation and subsequent review of the resident's medical records. These inaccuracies in MDS assessments highlight a failure in the facility's assessment processes, as noted by the survey team.
Failure to Implement Dietary Care Plan for Lactose Intolerant Resident
Penalty
Summary
The facility staff failed to develop and implement a comprehensive person-centered dietary care plan for a resident who was lactose intolerant. Despite the resident's daughter informing the facility on several occasions about the lactose intolerance, the facility continued to send milk on the resident's tray. The resident had a severe cognitive impairment, as indicated by a BIMS score of 3 out of 15, and had multiple diagnoses including Arteriosclerotic Heart Disease, Hypertension, and Diabetes Mellitus Type 2. The dietary care plan did not reflect the resident's lactose intolerance, which was a significant oversight. Interviews with facility staff revealed a lack of clarity regarding responsibility for updating the care plan. The dietary manager stated that the registered dietician was responsible for care plans, while the administrator later clarified that the MDS nurse was responsible for updates. The facility did not provide a care plan policy when requested, instead referencing the RAI manual for care planning guidelines. This lack of coordination and communication among staff contributed to the deficiency, as the resident's dietary needs were not adequately addressed in the care plan.
Failure to Update Resident Care Plan Post-Catheter Removal
Penalty
Summary
The facility staff failed to ensure the comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team. Specifically, the care plan was not updated to reflect the discontinuation of an indwelling catheter, which had been removed on 7/8/24. Despite the catheter's removal, the care plan still included a focus area indicating the resident required a catheter, with a revision date of 8/8/24. This oversight was identified during a surveyor's observation on 10/15/24, when it was noted that the resident did not have an indwelling catheter. The resident in question had a diagnosis list that included Alzheimer's Disease, Atrial Fibrillation, Diabetes Mellitus Type 2, Neuromuscular Dysfunction of Bladder, Bipolar Disorder, and Chronic Viral Hepatitis C. The most recent Minimum Data Set (MDS) assessment indicated severe cognitive impairment. During an interview, an LPN confirmed the catheter had been discontinued and reviewed the electronic health record, which corroborated the discontinuation date. The facility's failure to update the care plan was discussed with various staff members, including the administrator and director of nursing, but no care plan policy was provided to the survey team before the exit conference.
Failure to Obtain Physician's Order for Oxygen Administration
Penalty
Summary
The facility staff failed to obtain a physician's order for oxygen for a resident diagnosed with chronic obstructive pulmonary disease (COPD), morbid obesity, heart failure, and hypertension. The resident, who had intact cognition, was observed using oxygen via nasal cannula at a setting of 4 liters per minute (LPM) in their room. However, the resident believed they were receiving 2 LPM and stated they used oxygen all the time. A review of the clinical record revealed an order for C-PAP use at night with oxygen at 2 LPM as needed during the day, but no order for continuous oxygen at 4 LPM. Interviews with facility staff, including a Registered Nurse (RN) and a Licensed Practical Nurse (LPN), indicated uncertainty about the resident's oxygen order. The RN was unable to locate an order for 4 LPM, and the LPN mentioned that the resident had been back and forth to the hospital, which might have caused confusion about the order. The LPN checked the resident's oxygen saturation, found it to be 92%, and subsequently obtained an order for oxygen at 2 LPM as needed. The facility's policy stated that oxygen should be administered under a physician's order, except in emergencies. This issue was discussed with the facility's administration team, but no further information was provided before the exit conference.
Inadequate Disinfection of Glucometers
Penalty
Summary
The facility staff failed to maintain proper infection prevention and control processes during the use of Point of Care Devices, specifically glucometers, which were used on multiple residents. During a medication pass observation, an LPN was seen cleaning a glucometer with alcohol prep pads after obtaining a blood sugar level from a resident. When questioned, the LPN stated that using alcohol pads was the standard practice for cleaning glucometers before and after each patient. This practice was confirmed by the Assistant Director of Nursing, who also mentioned that education for all nurses had already begun. Upon reviewing the EvenCare Blood Glucose Monitoring System User's Guide, it was noted that the glucometers should be disinfected with specific EPA-registered disinfectant wipes, not alcohol prep pads. The facility's policy, revised in September 2024, also required glucometers to be cleaned and disinfected according to the manufacturer's instructions using an EPA-registered healthcare disinfectant effective against certain viruses. Despite this policy, the staff continued using alcohol pads, a practice reportedly carried over from COVID-19 protocols, as stated by the Director of Nursing. This discrepancy between the facility's policy and actual practice was discussed with the Director of Nursing, Regional Director of Clinical Services, and the Administrator, but no further information was provided before the exit conference.
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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 Lebanon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Deer Meadows Rehabilitation And Nursing | 13.7 mi | ★★★★★ | 0 | 0 |
| Abingdon Health & Rehab Center | 15.2 mi | ★★★★★ | 0 | 0 |
| The Rehab Center At Bristol | 18.5 mi | ★★★★★ | 8 | 0 |
| Clinch Valley Medical Center | 20.8 mi | ★★★★★ | 0 | 0 |
| Nhc Healthcare, Bristol | 21.6 mi | ★★★★★ | 3 | 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.