Maple Woods Manor: Resident Left in Soaked Urine - MI
That is what federal inspectors documented at Maple Woods Manor following a complaint inspection on August 13, 2025.
The sequence of events, as described by Unit Manager B during an interview that morning, began sometime before 9:30 a.m., when the resident, identified in inspection records only as R1, got up for the day. At around 10 a.m., Unit Manager B said she checked on the resident herself. Pants clean, no odor. Whatever had happened had not yet become visible.
Then the daughter arrived at 11 a.m.
By then, Unit Manager B said, the urine had soaked through the resident's pants entirely and into the cushion of her wheelchair. She described it as "very odorous." She took the resident straight to the shower.
Before she did, she asked CNA D, the aide assigned to R1 that day, why the resident had not been changed. CNA D told her there were no linens available to perform perineal care.
Unit Manager B had to walk to the laundry herself to get clean linen. She brought some back for CNA D and then took R1 for a shower.
The inspection report notes that the facility has no written policy specifying how much linen should be kept on hand. Instead, the facility follows what are called par levels, meaning the amount of linen stocked is calculated based on the number of residents in the building at any given time. Whether those par levels were being met that morning, whether linen had simply not been restocked, whether this was a recurring problem or a one-time gap, the inspection record does not say.
What it does say is that when a resident needed basic hygiene care, the person responsible for providing it told her supervisor she had nothing to do it with.
The violation was cited under F0584, which covers the basic standard that residents must receive care in a safe and clean environment. Inspectors classified the level of harm as minimal harm or potential for actual harm, affecting some residents.
That classification is the lowest tier available. It does not mean nothing happened. R1 sat in soaked clothing long enough for urine to penetrate through to the furniture beneath her. Her daughter, not a staff member, is what made the situation visible.
Unit Manager B said she was not sure how long R1 had been sitting that way. The CNA told her R1 had gotten up around 9:30 a.m. There is at least a ninety-minute window between when the resident rose and when her daughter walked in and found her that way. Unit Manager B herself had looked at R1 an hour before the daughter arrived and described her as clean and dry. That means the window when no one caught it, or no one acted on it, was somewhere inside that last hour.
CNA D's explanation was not that she had forgotten, or that she was busy, or that she hadn't checked. It was that she lacked the supplies to do the job.
That is a different kind of problem. An aide who forgets or delays can be retrained or disciplined. An aide who has no linens is working inside a system that did not give her what she needed. Whether that system failed once or fails regularly, the inspection does not resolve.
What the inspection does resolve is this: on the morning of August 13, 2025, a resident at Maple Woods Manor sat wet and odorous in her wheelchair while her assigned caregiver waited for supplies, and it was the resident's own daughter who finally made it stop.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Maple Woods Manor from 2025-08-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 3, 2026 · Our methodology
Maple Woods Manor in Clio, MI was cited for violations during a health inspection on August 13, 2025.
That is what federal inspectors documented at Maple Woods Manor following a complaint inspection on August 13, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.