Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens 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 Nursing Home during CMS and state inspections, most recent first.
A resident with dementia experienced ongoing behavioral symptoms, including aggression, hoarding, and agitation, without staff adequately assessing root causes or implementing individualized, non-pharmacological interventions. Staff relied on redirection and escalated to antipsychotic medications not approved for dementia-related behaviors, without thorough documentation or care plan updates. The resident suffered lethargy, weight loss, and new skin breakdown, while the facility failed to follow its own dementia care policies.
The facility did not ensure that controlled substance counts for multiple residents were reconciled and documented by two qualified staff at each shift change, as required by policy. Over several days, there was no documentation or nurse signatures verifying narcotic counts for the A-hall medication cart, despite the presence of various Schedule II, IV, and V medications. Interviews with nursing staff and the DON confirmed that the required procedures were not consistently followed or documented.
A resident with paraplegia and moderate cognitive impairment reported a sexual abuse allegation to a CNA, who informed an LPN and RN, but the incident was not escalated to the DON or Administrator as required. Multiple staff members failed to report the allegation to the appropriate authorities, resulting in a delay of four days before the Administrator was informed. The Administrator then failed to notify the state agency within the required two-hour timeframe, violating the facility's abuse reporting policy.
A resident with paraplegia and moderate cognitive impairment reported discomfort and possible inappropriate behavior by a CNA. The facility's investigation into the abuse allegation was incomplete, lacking required documentation such as written statements from involved parties, interviews with the accused CNA and the resident, and a summary of findings, as required by facility policy. Staff interviews revealed confusion about investigation procedures, and key investigative steps were not taken.
A resident with aphasia and hemiplegia was verbally abused by an LPN who raised their voice, repeatedly urged the resident to hurry, and threatened to call the police when the resident attempted to communicate their needs. The incident was witnessed by another resident and confirmed by staff and family interviews, resulting in the resident feeling upset and fearful of the LPN.
The facility did not have a licensed nursing home administrator, as required for effective administration. The previous administrator resigned, and the Human Resources Director, with an expired temporary license, was managing daily operations. The Board of Directors and the Director of Accounting confirmed the absence of a licensed administrator, leading to a deficiency in compliance.
Failure to Provide Individualized Dementia Care and Inadequate Behavioral Management
Penalty
Summary
Facility staff failed to provide high-quality, compassionate, and individualized care to a resident with dementia, as required by facility policy and best practices for dementia care. The staff did not adequately assess or address the root causes and triggers of the resident's behavioral symptoms, such as hoarding napkins and washcloths, aggression toward staff and peers, and repeated requests for snacks and fluids. Documentation repeatedly lacked evidence of staff attempts to identify antecedents or implement non-pharmacological interventions before resorting to medication changes. Instead, staff primarily used redirection, which was often ineffective, and escalated to antipsychotic medications without clear documentation of failed non-pharmacological strategies or thorough behavioral assessments. The resident, who had diagnoses of Alzheimer's, dementia, and anxiety, experienced a decline in well-being, including lethargy, weight loss, agitation, physical altercations, and new skin breakdown. Despite ongoing behavioral issues, staff did not consistently document or investigate potential triggers such as pain, hunger, thirst, boredom, or environmental factors. There was also a lack of individualized interventions, such as providing the resident with their own supply of napkins or addressing possible discomfort with toileting routines. The care plan was not updated to reflect ongoing behavioral changes or to include new strategies based on observed triggers and outcomes. Additionally, the facility's use of antipsychotic medications, including Seroquel, Haldol, and Risperidone, was not in accordance with approved indications for elderly residents with dementia. Orders for these medications were made without sufficient documentation of behavioral assessments or evidence that non-pharmacological interventions had been exhausted. The facility failed to follow its own dementia care policies, which emphasize person-centered care, regular review of care plans, and prioritization of non-pharmacological interventions. As a result, the resident's dignity, well-being, and independence were not adequately supported, and the unique challenges posed by dementia were not effectively addressed.
Failure to Reconcile and Document Controlled Substance Counts per Policy
Penalty
Summary
The facility failed to ensure that inventories of Schedule II, IV, and V controlled substance medications were reconciled by at least two qualified staff members each shift, as required by facility policy. Multiple days were identified where there was no documentation of shift-to-shift narcotic medication counts, no nurse signatures on narcotic count sheets, and no total card counts for the A-hall medication cart. This lack of documentation occurred across all three daily shifts on several dates, and included the absence of required log sheets for certain periods. The facility's policy required two staff members to count and sign off on all controlled substances at the start and end of each shift, but this was not consistently done. Review of individual resident narcotic count sheets confirmed that various controlled substances, including Ativan, morphine sulfate, hydrocodone/acetaminophen, Roxanol, Lyrica, tramadol, and oxycodone, were stored in the narcotic lock box for ten residents. Despite the presence of these medications, the required documentation and reconciliation procedures were not followed. Observations and record reviews showed that for several days, there were no signatures or documentation to verify that the counts were completed as per policy. Interviews with nursing staff and the Director of Nursing revealed a lack of adherence to the established procedures for narcotic counts. Staff acknowledged that two nurses were supposed to count and sign for the narcotics at each shift change, but this was not consistently practiced. The Director of Nursing and the Administrator both stated that they expected staff to complete and document the narcotic counts at every shift change, but were unaware of the missing documentation until it was brought to their attention during the survey.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to follow its policy regarding the timely reporting of an allegation of sexual abuse involving a resident with paraplegia and moderate cognitive impairment. The resident reported to a CNA that a staff member had engaged in sexually inappropriate behavior, including stroking the resident's hair and handling women's underwear in a suggestive manner. The CNA reported the allegation to an LPN, who then informed an RN, but the information was not escalated to the Director of Nursing (DON) or the Administrator as required by facility policy. Despite multiple staff members being made aware of the allegation, including the CNA, LPN, and RN, none of them reported the incident to the DON or Administrator until four days after the initial report. The RN, who was the nursing supervisor at the time, did not believe the allegation and failed to notify the appropriate authorities or follow the established reporting protocol. The DON and Assistant DON were also not informed in a timely manner, and the Administrator only became aware of the situation after several days had passed. When the Administrator was finally informed, she did not notify the state agency within the required two-hour window, instead reporting the incident several hours later. The facility's policy clearly states that allegations of abuse must be reported to the state agency immediately, but no later than two hours after the allegation is made. The failure to promptly report the allegation and initiate an investigation as required by policy and regulation constitutes a deficiency in the facility's abuse reporting procedures.
Failure to Thoroughly Investigate Abuse Allegation per Facility Policy
Penalty
Summary
The facility failed to provide evidence that allegations of abuse were thoroughly investigated according to its own policy for one resident out of a sample of eight. The resident in question had paraplegia and moderate cognitive impairment, but was able to make himself/herself understood and had no history of hallucinations, delusions, or behavioral issues. The resident reported discomfort with a CNA, describing incidents where the CNA stroked the resident's hair and was seen handling women's underwear in a manner that made the resident uncomfortable. When the allegation was reported, the administrator initiated some steps, such as contacting the police and the resident's next of kin, and collecting statements from several staff members. However, the investigation did not include a written, signed statement from the resident or the accused CNA, nor documentation of the resident's refusal to provide a statement. The accused CNA was not contacted by the facility regarding the allegation. Additionally, there was no documentation of interviews conducted or attempted with the resident or other residents, and no summary of the investigation or corrective actions taken was included in the records. Interviews with staff revealed confusion and lack of clarity regarding the investigation process. Several staff members, including the DON and nursing staff, indicated they had not initiated or participated in an investigation into the abuse allegation. The DON, who was responsible for Human Resources duties, did not recall being informed of the allegation in a timely manner and did not conduct interviews with the resident or other residents. The administrator did not review available camera footage related to the incident. The facility's documentation did not meet the requirements outlined in its own abuse investigation policy.
Verbal Abuse of Resident by LPN During Assistance
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, aphasia, and hemiplegia was subjected to verbal abuse by an LPN. The resident, who had difficulty communicating due to aphasia but was cognitively intact and able to understand others, attempted to express specific needs while trying to wheel themselves to the bathroom. The LPN became agitated, repeatedly raised their voice, and told the resident to "come on" while the resident tried to communicate and requested more time. When the resident attempted to touch the LPN's hand to gain attention, the LPN jerked away and threatened to call the police, causing the resident to feel upset and scared. Multiple interviews corroborated the incident. Another resident reported hearing the LPN yelling and threatening to have the resident arrested, and noted that the affected resident was visibly depressed afterward. Staff interviews revealed that the LPN expressed frustration about the resident's behavior and stated an unwillingness to continue caring for the resident. The resident's family member was contacted by the resident, who was upset and crying about the incident, and subsequently requested that the LPN not be assigned to the resident. The facility's policy requires all residents to be free from abuse, including verbal abuse, and mandates staff training on abuse prevention and reporting. The DON and administrator both acknowledged that the LPN's actions constituted abuse and violated expectations for treating residents with dignity and respect. The administrator was not aware of the incident until informed by the surveyor, and the event was confirmed through interviews with the resident, family, staff, and other residents.
Absence of Licensed Administrator in Facility
Penalty
Summary
The facility failed to ensure that a licensed nursing home administrator was employed, which is a requirement for effective and efficient administration. The facility had a census of 62 residents, with 23 requiring extensive assistance for activities of daily living. The facility's assessment outlined the need for various services, including ADL assistance, restorative nursing, and specialized care, and specified that an administrator was part of the required administrative staff. However, the facility did not have a licensed administrator at the time of the survey. Interviews revealed that the previous administrator had resigned, and the Human Resources Director, who held a temporary emergency license that had expired, was managing the daily operations. The Director of Accounting confirmed the absence of a licensed administrator, and the Board of Directors' President indicated that the Human Resources Director and the Board were handling the facility's operations. This lack of a licensed administrator constitutes a deficiency in the facility's compliance with regulatory requirements.
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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 Palmyra
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Luther Manor Retirement & Nursing Center | 1.9 mi | — | 36 | 0 |
| Beloved Health And Rehabilitation Center | 8.1 mi | — | 0 | 0 |
| Beth Haven Nursing Home | 9.1 mi | — | 0 | 0 |
| Sunset Home | 11.5 mi | — | 4 | 2 |
| Good Samaritan Home | 11.9 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 August 2026) and official state health department websites.