Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Maple Lawn Medical Care Facility during CMS and state inspections, most recent first.
A resident with dementia experienced undignified treatment when an LPN insisted the resident swallow a new pill despite repeated statements of inability, used vulgar language, and failed to respect the resident's distress during medication administration. The incident was witnessed by a medical assistant and later investigated by the facility.
A resident with Alzheimer's and severe cognitive impairment exhibited combative behaviors during care, resulting in a significant skin tear on the forearm. Despite training on handling difficult behaviors, a CNA continued care without stopping or seeking help, leading to the injury. Staff interviews revealed a lack of consistent documentation and communication about the resident's behaviors, contributing to the deficiency.
The facility failed to conduct proper infection surveillance and reporting, affecting 100 residents. The ICP did not complete written reports since February 2024, only providing verbal updates. Nosocomial infection rates and urinary tract infections without catheters increased, but no root cause analysis or corrective actions were documented. Infection maps lacked proper identification, and the DON was aware of the issues but could not provide evidence of corrective actions.
The facility failed to provide adequate staffing, impacting restorative/mobility services and residents' shower preferences. The Mobility RN was often reassigned to floor duties, leaving residents without recommended mobility care. Residents reported receiving fewer showers than preferred due to staffing shortages, confirmed by EMR records. The DON acknowledged the absence of a restorative program, and the RN Supervisor noted efforts to accommodate additional shower requests when possible.
A facility failed to honor a resident's right to choose his room, resulting in emotional distress. The resident, diagnosed with Major Depressive Disorder, was initially promised a move to a room near his wife, but the plan was canceled due to objections from the wife's family. Despite the resident's right to choose, the facility prioritized family concerns, leading to the resident's increased sadness and frustration.
Two residents in a long-term care facility did not receive necessary restorative services to maintain mobility due to staffing shortages. One resident, with a recent femur fracture, experienced anxiety as restorative services were not initiated after therapy ended. Another resident, with severe dementia and a hip fracture, was not on a restorative plan as the facility had discontinued the program. The Mobility RN was often pulled to work on the floor, affecting the delivery of mobility services.
The facility did not include total nursing hours and actual hours worked on the posted Daily Nurse Schedule, which was accessible to residents and visitors. Interviews revealed that the Nursing Staff Scheduler, DON, and NHA were unaware of the requirement to post actual worked hours, with the schedule only listing the number of staff scheduled to work.
Failure to Ensure Dignified and Respectful Medication Administration
Penalty
Summary
A resident with dementia and behavioral disturbances was subjected to undignified treatment during medication administration. According to facility documentation and staff interviews, a Licensed Practical Nurse (LPN) entered the resident's room to administer a new stomach pill that could not be crushed. The resident was lying flat in bed and repeatedly expressed an inability to swallow the pill, with water running out of his mouth onto his chest. Despite these difficulties, the LPN continued to insist that the resident swallow the pill and used vulgar language during the interaction. The resident verbally expressed distress, stating that the nurse was killing him. A Medical Assistant present in the room corroborated the resident's repeated statements of being unable to swallow the pill and reported the LPN's use of inappropriate language. The facility's investigation found that the resident had no recollection of the incident when later interviewed by a social worker. The LPN involved had received education on resident rights in the previous three years. The incident was reported after the resident's death, and the LPN was not available for interview during the investigation.
Failure to Implement Person-Centered Care for Dementia Resident
Penalty
Summary
The facility failed to develop and implement person-centered care approaches for a resident diagnosed with dementia, leading to a significant injury. The resident, who was admitted with Alzheimer's and had severely impaired cognitive skills, was observed to have behaviors of being combative during care. On one occasion, while a Certified Nurse Aide (CNA) was providing morning care, the resident became combative, resulting in a severe skin tear on the right forearm. The injury was significant enough to require emergency room treatment, where it was noted that the tissue was avulsed to the subcutaneous fat, exposing muscle. The CNA reported that the resident exhibited combative behaviors daily during care, including swatting at staff and twisting her own arms. Despite these behaviors, the CNA continued to provide care without stopping or seeking additional assistance, which was contrary to the training received on handling difficult behaviors in residents with dementia. The CNA admitted to not stopping the care when the resident became combative, which likely contributed to the injury. Interviews with staff revealed that the resident's aggressive behaviors were known, but there was a lack of consistent documentation and communication regarding these behaviors. The Social Worker noted that behavior logs were discontinued due to being blank, and the Nursing Home Administrator and Director of Nursing confirmed that staff training emphasized ensuring resident safety and reapproaching if issues arose during care. However, these protocols were not effectively implemented in this case, leading to the deficiency.
Inadequate Infection Surveillance and Reporting
Penalty
Summary
The facility failed to provide appropriate infection surveillance for all residents, impacting 100 current residents, and did not take necessary actions to track, trend, and formulate corrective actions to decrease the spread of nosocomial infections. The Infection Control Preventionist (ICP) C, who has been in the position since February 2024, was responsible for data collection and review regarding infections. However, ICP C had not completed written reports since February 2024, citing being busy as the reason, and only provided verbal reports to the Infection Control Committee and Quality Assurance Committee. Despite the presence of nosocomial infection rates and urinary tract infections without catheters, no root cause analysis or corrective actions were documented. The facility's line listing showed fluctuating nosocomial infection rates and an increase in urinary tract infections without catheters, yet no reports were provided to address these issues. Infection maps lacked proper identification of community-acquired or in-house acquired infections, as indicated by the map legend. The Director of Nursing (DON) B acknowledged the expectation for monthly reports and was aware of the increase in urinary tract infections but could not provide evidence of education or actions taken in response. Additionally, the Quality Assurance Minutes inaccurately recorded that ICP C presented reports, despite the absence of completed reports after February 2024.
Inadequate Staffing Affects Mobility Services and Shower Frequency
Penalty
Summary
The facility failed to ensure adequate staffing to meet the needs of residents, specifically in providing restorative/mobility services and honoring residents' preferences for shower frequency. The facility assessment indicated that 102 residents required assistance with bathing, yet there were no restorative nursing assistants available, and the facility planned to add two staff once staffing levels were reached. Interviews revealed that the Mobility RN was frequently pulled from her duties to work as a floor nurse, resulting in residents not receiving recommended mobility services. The Director of Nursing (DON) confirmed the absence of a restorative program since January 2024 and stated that CNAs were needed on the floor, impacting the mobility program. Additionally, residents expressed dissatisfaction with the frequency of showers, preferring two showers per week, but were informed by staff that there was insufficient staffing to accommodate this preference. The Electronic Medical Record (EMR) confirmed that residents were receiving showers only once per week. The RN Supervisor explained that staff scheduled for baths and showers were not assigned to general care, and efforts were made to accommodate additional shower requests if possible. However, the lack of adequate staffing hindered the facility's ability to meet residents' preferences consistently.
Failure to Honor Resident's Right to Room Choice
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not allowing a resident to relocate to a room of his choice, which was across from his wife's room. This decision resulted in emotional distress for the resident, who expressed feelings of frustration, anger, and depression. The resident, who has a diagnosis of Major Depressive Disorder and intact cognition, was initially informed that he could move to a room closer to his wife. However, the plan was canceled by the Nursing Home Administrator due to objections from the wife's family, despite the resident's expressed desire and right to make this choice. The resident's emotional state was further documented in a psychiatry note, which indicated that he felt lied to and was experiencing increased sadness and sleep disturbances due to the situation. The Social Worker confirmed that the resident technically had the right to choose his room, but the facility's decision was influenced by the family's concerns. The resident's ongoing distress was evident during observations, where he was noted to have a flat affect and expressed bitterness about the situation, stating that he would not feel good until he could be near his wife.
Failure to Provide Restorative Services Due to Staffing Shortages
Penalty
Summary
The facility failed to provide restorative services to maintain mobility for two residents, resulting in anxiety and unmet goals. Resident #98, who had a left femur fracture repair, was observed sitting in a wheelchair and expressed anxiety due to the lack of restorative nursing services after her therapy ended. Despite recommendations for a range of motion program, the services had not started, and there was a lack of communication regarding her participation in scheduled exercise activities. The Mobility RN confirmed that Resident #98 was not on a restorative/mobility program due to staffing shortages. Resident #44, who had multiple diagnoses including severe vascular dementia and a recent hip fracture, was also not receiving restorative services. After being readmitted to the facility following a fall and surgical repair, Resident #44's therapy was discontinued, and a restorative program was supposed to start. However, the Director of Nursing stated that the facility had not had a restorative program since January 2024, and the mobility program was also affected by staffing issues. The Mobility RN, who was responsible for the program, was frequently pulled to work on the floor, limiting the number of residents she could see. Both residents experienced a lack of restorative care due to insufficient staffing, which led to the discontinuation of the facility's restorative and mobility programs. The facility's inability to provide these services resulted in unmet goals for maintaining the residents' mobility and contributed to Resident #98's anxiety. The report highlights the facility's failure to follow through with recommended care plans due to staffing constraints.
Failure to Post Actual Nursing Hours Worked
Penalty
Summary
The facility failed to include daily nursing total numbers and actual hours worked on the posted Daily Nurse Schedule, which was accessible to residents, family, and visitors. During an interview, the Nursing Staff Scheduler was unable to provide the total number of hours to be worked for each shift or the total number of hours worked for previous shifts. The document posted, titled Daily Nurse Schedule, only listed the names and shifts of the staff scheduled to work on that date, without indicating the total hours to be worked. Further interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) revealed that neither was aware of the requirement to post actual worked hours. The NHA explained that the schedule only listed the total number of persons working, and anyone reviewing the hours would have to calculate the total hours themselves. The NHA requested information on the requirement to post actual worked hours, indicating a lack of awareness of this regulatory requirement.
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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 Coldwater
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Laurels Of Coldwater | 0.7 mi | — | 6 | 0 |
| Hillsdale County Medical Care Facility | 17.8 mi | — | 14 | 0 |
| Hillsdale Hospital Mcguire & Macritchie Long Term | 18.4 mi | — | 2 | 0 |
| Northern Lakes Nursing And Rehabilitation Center | 20.1 mi | — | 9 | 2 |
| Lakeland Rehab And Healthcare Center | 20.1 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.