Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 19, 2025
Visit Reason
The document reflects acceptance of the facility's credible allegation of substantial compliance and Plan of Correction, leading to certification in compliance effective June 10, 2025.
Findings
The facility was found to be in substantial compliance based on the Plan of Correction submitted and accepted by the surveyors.
Inspection Report
Annual Inspection
Census: 38
Deficiencies: 2
May 22, 2025
Visit Reason
The inspection was conducted as the facility's annual recertification survey from May 19, 2025 to May 22, 2025.
Findings
The facility was found deficient in dialysis services due to failure to complete pre and post dialysis assessments for one resident, and in infection prevention and control due to failure to utilize enhanced barrier precautions for one resident with an indwelling urinary catheter.
Severity Breakdown
S: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to complete pre and post dialysis assessments for Resident #24. | S |
| Failure to utilize enhanced barrier precautions for Resident #39 with an indwelling urinary catheter. | S |
Report Facts
Census: 38
Dialysis assessments missing: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurses Aid (CNA) | Named in infection control deficiency for failing to wear gown during catheter care |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Explained expectations for dialysis assessments and infection prevention |
| Provisional Administrator | Provisional Administrator | Signed the report and plan of correction |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 18, 2025
Visit Reason
A complaint survey was conducted on 2/17-18/2025 in response to complaint #126629-C and self reports #126271-I and #126185-I.
Findings
The complaint and self reports were investigated and found to be not substantiated according to the Code of Federal Regulations (42FR) Part 483, Subpart B-C.
Complaint Details
Complaint #126629-C and self reports #126271-I and #126185-I were investigated and found not substantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 2, 2024
Visit Reason
A complaint investigation was conducted for complaints #122733-C and #124424-C, as well as facility reported incidents #123439-I and #124317-I from November 25, 2024 to December 2, 2024.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Complaint Details
Investigation involved complaints #122733-C and #124424-C and facility reported incidents #123439-I and #124317-I; facility found in substantial compliance.
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 1, 2024
Visit Reason
An annual recertification survey and investigation of facility reported incident #120125-I was conducted from July 29, 2024 to August 1, 2024.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 8, 2024
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of credible allegation of substantial compliance and certification of the facility.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, resulting in certification effective January 8, 2024.
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 6
Dec 21, 2023
Visit Reason
The inspection was conducted as the facility's annual recertification survey and included investigation of complaint #116130-C and facility reported incidents #114345-I and #116588-I.
Findings
The facility was found deficient in multiple areas including failure to provide timely Medicare notices to residents, inadequate bed hold policy documentation, inaccurate resident assessments, failure to transmit Minimum Data Set (MDS) assessments timely, inaccurate coding of assessments, failure to meet professional standards in care plans, and medication administration errors. The facility reported a census of 37 residents during the survey.
Complaint Details
Complaint #116130-C was investigated and found not substantiated. Facility reported incidents #114345-I and #116588-I were also not substantiated.
Severity Breakdown
SS=B: 4
SS=D: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to provide Medicare Notice of Non-Coverage (NOMNC) notification to residents or their legal representatives two days prior to ending services for sampled residents. | SS=B |
| Failed to provide bed hold notice for residents prior to transfer or discharge. | SS=B |
| Failed to electronically transmit Minimum Data Set (MDS) assessments timely for 3 of 3 residents reviewed. | SS=B |
| Failed to accurately complete Minimum Data Set (MDS) assessments reflecting residents' status for 2 of 12 residents reviewed. | SS=B |
| Failed to meet professional standards in comprehensive care plans including medication administration for insulin for 1 resident. | SS=D |
| Failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program for repeated citations. | SS=D |
Report Facts
Residents reviewed: 12
Residents reviewed for MDS transmission: 3
Residents receiving Medicare services: 2
Census: 37
Insulin units: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Betty Davis | Administrator | Signed the plan of correction and acknowledged findings |
| Staff A | Licensed Practical Nurse (LPN) | Reported Resident #9 uses half rails and does not utilize restraints |
| Staff B | Licensed Practical Nurse (LPN) | Observed administering insulin to Resident #4 and reported lack of knowledge on priming insulin pen |
| Director Of Nursing (DON) | Director Of Nursing | Reported bed hold documentation expectations and MDS assessment miscoding |
| MDS Coordinator | Reported on MDS transmission, coding errors, and use of RAI Manual | |
| Administrator | Reported facility did not have a beneficiary notice policy and monitored compliance |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 1, 2023
Visit Reason
A complaint investigation was conducted for complaints #109586-C and #110658-C, along with facility reported incidents #107010-I and #109680-I, from January 30 to February 1, 2023.
Findings
The facility was found to be in substantial compliance with no deficiencies noted.
Complaint Details
Complaint investigation for complaints #109586-C and #110658-C and facility reported incidents #107010-I and #109680-I; facility found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 11, 2022
Visit Reason
The document is a plan of correction submitted following a prior inspection, indicating acceptance of the facility's credible allegation of compliance.
Findings
The facility was certified in compliance effective June 27, 2022, based on acceptance of the credible allegation of compliance and plan of correction. No specific deficiencies are detailed in this document.
Report Facts
Certification effective date: Facility certified in compliance effective June 27, 2022
Inspection Report
Annual Inspection
Census: 43
Deficiencies: 3
Jun 23, 2022
Visit Reason
The inspection was conducted as part of the facility's annual health survey and review of compliance with federal regulations.
Findings
The facility was found deficient in ensuring CPR/DNR status consistency across clinical records for one resident, failure to notify three residents of Medicare Non-Coverage notices prior to discharge from Medicare Part A stays, and failure to complete and update the Facility Assessment annually or as needed.
Severity Breakdown
SS=B: 1
SS=C: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure CPR/DNR status matched across clinical records for Resident #17. | — |
| Failure to notify 3 residents (Resident #6, #27, and #45) of their Notice of Medicare Non-Coverage two days prior to discharge from Medicare Part A stay. | SS=B |
| Failure to complete, document, review, and update the Facility Assessment annually and as necessary. | SS=C |
Report Facts
Residents reviewed for CPR/DNR status: 16
Residents not notified of Medicare Non-Coverage: 3
Facility census: 43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding CPR/DNR status consistency | |
| Administrator | Interviewed regarding Medicare Non-Coverage notices and Facility Assessment policy | |
| Staff A | Prior Administrator | Last person to review Facility Assessment in February 2021 |
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 6
Feb 25, 2021
Visit Reason
The Iowa Department of Inspection and Appeals conducted a recertification survey of Maple Crest Manor to assess compliance with Medicare Conditions of Participation.
Findings
The facility was found not in compliance with multiple deficiencies including failure to provide required CMS forms, inadequate supervision leading to resident injury, incomplete physician documentation, lack of transfer agreements with hospitals, failure to hold quarterly Quality Assessment and Assurance meetings, and deficiencies in infection prevention and control practices.
Severity Breakdown
SS=D: 4
SS=J: 1
SS=E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to provide required CMS form 10055 at completion of skilled services for 1 of 3 residents reviewed. | SS=D |
| Failed to keep 1 of 5 wandering residents safe from injury from an unsupervised steam table resulting in burns and lack of adequate supervision. | SS=J |
| Failed to have written, signed, and dated physician progress notes and orders within the required timeframe for 5 of 9 residents reviewed. | SS=D |
| Failed to have a written transfer agreement with one or more hospitals in effect. | SS=D |
| Failed to hold quarterly Quality Assessment and Assurance meetings with proper documentation. | SS=D |
| Failed to follow infection prevention and control standards including hand hygiene, PPE use, cleaning protocols, and screening procedures. | SS=E |
Report Facts
Facility census: 40
Temperature of steam table: 283
Number of wandering residents: 5
Number of residents reviewed for CMS form: 3
Number of residents reviewed for physician documentation: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Night Cook | Reported steam table is plugged in at 3:30 p.m. and CNAs watch for residents |
| Staff F | Certified Nurses Aid (CNA) | Reported expectation to keep an eye on wandering residents and lack of training on lift cleaning |
| Staff G | Registered Nurse (RN) | Reported need to keep an eye on Resident #40 around steam table |
| Director of Nursing | Director of Nursing (DON) | Confirmed lack of one-to-one staffing for wandering residents and failure to complete investigation of burn incident |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Reported expectations for hand hygiene and PPE use, and lack of annual infection control review |
| Dietary Manager | Dietary Manager (DM) | Observed leaving steam table unattended and reported burn incident |
| Staff C | Registered Nurse (RN) | Reported burn incident and resident complaints of pain |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Oct 27, 2020
Visit Reason
A Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on October 26 - 27, 2020.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jun 23, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 6/23/20 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
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