Inspection visit
Inspection
16 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 16 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, observation, and staff interview the facility failed to provide food to a resident on the
behavioral unit when he requested something to eat because he was hungry. This affected one Resident
(#31) out of 15 residents who resided on the behavioral unit. The facility census was 65.
Findings include:
Medical record review revealed Resident #31 was admitted to the facility on [DATE]. Diagnoses included
altered mental status, epilepsy, dementia, anemia, moderate intellectual disabilities, anxiety, altered mental
status, and major depressive disorder. Review of the resident's quarterly Minimum Data Set (MDS) dated
[DATE] revealed the resident required supervision with one-person assistance for bed mobility, transferring
and bathing with moderately impaired cognition.
Observations on 10/24/18 at 10:20 A.M. through 10:45 A.M., revealed the resident asked State Tested
Nursing Assistant (STNA) #500 for a sandwich because he was hungry. STNA #500 initially told Resident
#31 to wait until lunch time. Resident #31 stressed to STNA #500 that he was hungry and could not wait for
lunch, even though lunch was scheduled at 11:00 A.M. Resident #31 stated again how hungry he was and
wanted a piece of bologna and bread. with ketchup. STNA #500 told Resident #31 that she was unable to
leave the unit and he had to wait until the nurse came back on the unit before she could leave the unit.
Resident #31 stated he was hungry and wanted to go back and lay down.
Interview with STNA #500 on 10/24/18 at 10:30 A.M. stated she thought Resident #31 wanted a bologna
sandwich instead of a turkey sandwich which was on the menu for the day.
Observation on 10/24/18 at 10:45 A.M., revealed Activity Aide (AA) #200 informed STNA #500 that the
resident was ready to eat now and could not wait for lunch. AA #200 asked STNA #500 to supervise
activities while she went to the kitchen and requested a sandwich for Resident #31.
Observation on 10/24/18 at 10:50 A.M., revealed AA #200 returned to the unit with a ham sandwich with
ketchup for Resident #31.
Interview on 10/24/18 at 10:55 A.M., revealed the Director of Nursing (DON) reported STNA #500's action
was unacceptable. The DON stated STNA #500 should have radioed the request for a sandwich to dietary
services, STNA #500 would not have to leave the floor to do this. Dietary services would radio back when
the sandwich was ready and the DON or someone else could have brought the sandwich to Resident #31.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 15
Event ID:
365557
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365557
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/25/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Maple Gardens Rehabilitiation and Nursing Center
515 South Maple Street
Eaton, OH 45320
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0550
Observation on 10/24/18 at 11:15 A.M., revealed lunch was served on the behavioral unit.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365557
If continuation sheet
Page 2 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365557
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/25/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Maple Gardens Rehabilitiation and Nursing Center
515 South Maple Street
Eaton, OH 45320
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
resident record review and staff interview, the facility failed to notify the resident/resident representative in
writing of the reason for a transfer to the hospital. Additionally, the facility failed to send a copy of the notice
to a representative of the Office of the State Long-Term Care Ombudsman. This affected two (#5 and #18)
of two residents reviewed for hospitalization. The census was 65.
Findings include:
1. Review of the medical record for Resident #5 revealed the resident was admitted to the facility on [DATE].
Diagnoses included diarrhea, diabetes mellitus type two, morbid obesity, chronic obstructive pulmonary
disease, hypertension, post traumatic stress disorder, stage three chronic kidney disease, heart failure,
depressive episodes and insomnia.
Review of a nurse progress noted dated 06/04/18 at 2:07 P.M. revealed Resident #5 was noted to have
critical laboratory results. Documentation revealed the resident was assessed to have shortness of breath
and four plus pitting edema. The certified nurse practitioner was made aware of the abnormal assessment
and critical lab results. A new order was received to send Resident #5 to the hospital for evaluation and
treatment. Review of a nurse progress note dated 6/04/18 at 8:06 P.M. revealed Resident #5 was admitted
to the hospital related to kidney failure.
Review of a nurse progress note dated 09/05/18 at 10:16 A.M. revealed Resident #5 was sent to the
hospital for evaluation and treatment at 9:30 A.M. Documentation revealed the resident returned to the
facility from the hospitalization on 09/07/18.
Review of Resident #5's minimum data set (MDS) assessments revealed discharge return anticipated MDS
assessments were completed on 06/04/18 and 09/05/18.
Continued review of the medical record for Resident #5 revealed no documentation the resident/resident
representative or ombudsman was notified in writing of the reason for Resident #5's hospital transfer.
Interview on 10/25/18 at 3:24 P.M. with social worker #100 verified the resident/resident representative was
not notified in writing of the reason of the hospital transfer. The social worker further verified the
ombudsman was not send a copy of the notice.
2. Review of the medical record for Resident #18 revealed he was admitted [DATE]. Diagnoses included
acute respiratory failure with hypoxia, sixth nerve palsy of an unspecified eye, amputation of lesser toe,
local lupus erythematosus, chronic kidney disease, stage 4, iron deficiency anemia, right bundle branch
block, protein-calorie malnutrition, non pressure chronic ulcer of right foot with unspecified severity,
hypo-osmolality and hyponatremia, hyperkalemia, paroxysmal atrial fibrillation, chronic viral hepatitis C,
type 2 diabetes with polyneuropathy, cocaine abuse in remission, bi polar disease, von willebrand's
disease, peripheral vascular disease, chronic embolism and thrombosis of deep veins of right lower
extremity, benign prostatic hyperplasia, cirrhosis of liver, hypertension, gastro-esophageal reflux disease,
and chronic pain syndrome.
Review of the Minimum Data Set (MDS) revealed he was cognitively intact and required supervision
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365557
If continuation sheet
Page 3 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365557
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/25/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Maple Gardens Rehabilitiation and Nursing Center
515 South Maple Street
Eaton, OH 45320
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0623
with eating and extensive assistance with activities of daily living (ADL's), bed mobility and transfers.
Level of Harm - Minimal harm
or potential for actual harm
Review of the progress notes dated 10/08/18 revealed Resident #18 went to the hospital due to critically
low labs.
Residents Affected - Few
During an interview in 10/25/18 at 2:30 P.M., the Administrator verified they had not provided notice to the
Ombudsman's office of residents transfer or discharges to the hospital.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365557
If continuation sheet
Page 4 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365557
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/25/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Maple Gardens Rehabilitiation and Nursing Center
515 South Maple Street
Eaton, OH 45320
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0625
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Notify the resident or the resident’s representative in writing how long the nursing home will hold the
resident’s bed in cases of transfer to a hospital or therapeutic leave.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of
the medical record for Resident #18 revealed he was admitted [DATE]. Diagnoses included acute
respiratory failure with hypoxia, sixth nerve palsy of an unspecified eye, amputation of lesser toe, local
lupus erythematosus, chronic kidney disease, stage 4, iron deficiency anemia, right bundle branch block,
protein-calorie malnutrition, non pressure chronic ulcer of right foot with unspecified severity,
hypo-osmolality and hyponatremia, hyperkalemia, paroxysmal atrial fibrillation, chronic viral hepatitis C,
type 2 diabetes with polyneuropathy, cocaine abuse in remission, bi polar disease, von willebrand's
disease, peripheral vascular disease, chronic embolism and thrombosis of deep veins of right lower
extremity, benign prostatic hyperplasia, cirrhosis of liver, hypertension, gastro-esophageal reflux disease,
and chronic pain syndrome.
Review of the Minimum Data Set (MDS) revealed he was cognitively intact and required supervision with
eating and extensive assistance with activities of daily living (ADL's), bed mobility and transfers.
Review of the progress notes dated 10/08/18 revealed Resident #18 went to the hospital due to critically
low labs.
During an interview on 10/25/18 at 2:30 P.M., the Administrator verified no bed hold notice was given to
Resident #18 when he was discharged to the hospital on [DATE].
Based on resident record review and staff interview, the facility failed to notify the resident/resident
representative of the bed hold and reserve bed payment policy upon transfer to the hospital. This affected
two (#5 and #18) of two residents reviewed for hospitalization. The census was 65.
Findings include:
1. Review of the medical record for Resident #5 revealed the resident was admitted to the facility on [DATE].
Diagnoses included diarrhea, diabetes mellitus type two, morbid obesity, chronic obstructive pulmonary
disease, hypertension, post traumatic stress disorder, stage three chronic kidney disease, heart failure,
depressive episodes and insomnia.
Review of a nurse progress noted dated 06/04/18 at 2:07 P.M. revealed Resident #5 was noted to have
critical laboratory results. Documentation revealed the resident was assessed to have shortness of breath
and four plus pitting edema. The certified nurse practitioner was made aware of the abnormal assessment
and critical lab results. A new order was received to send Resident #5 to the hospital for evaluation and
treatment. Review of a nurse progress note dated 06/04/18 at 8:06 P.M. revealed Resident #5 was admitted
to the hospital related to kidney failure.
Review of a nurse progress note dated 09/05/18 at 10:16 A.M. revealed Resident #5 was sent to the
hospital for evaluation and treatment at 9:30 A.M. Documentation revealed the resident returned to the
facility from the hospital on [DATE].
Review of Resident #5's minimum data set (MDS) assessments revealed discharge return anticipated MDS
assessments were completed on 06/04/18 and 09/05/18.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365557
If continuation sheet
Page 5 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365557
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/25/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Maple Gardens Rehabilitiation and Nursing Center
515 South Maple Street
Eaton, OH 45320
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0625
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Continued review of the medical record for Resident #5 revealed no documentation the resident/resident
representative was made aware of the facility's bed hold and reserve payment policy upon transfer to the
hospital.
Interview on 10/25/18 at 3:24 P.M. with social worker #100 verified the resident/resident representative was
not made aware of the bed hold and reserve bed payment policy.
Event ID:
Facility ID:
365557
If continuation sheet
Page 6 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365557
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/25/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Maple Gardens Rehabilitiation and Nursing Center
515 South Maple Street
Eaton, OH 45320
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of
the medical record for Resident #66 revealed she was admitted initially on 03/21/17 with re-entry on
05/15/18. Diagnoses included osteomyelitis of vertebra of lumbar region, edema, hypocalcemia, abdominal
pain, contusion of abdominal wall, idiopathic peripheral autonomic neuropathy, anemia, hypokalemia,
sepsis, elevated erythrocyte sedimentation rate, elevated C-reactive protein, tobacco use, radiculopathy,
chronic hepatitis C, acute post-hemorrhagic anemia, constipation, insomnia, discitis of the lumbar region,
bacteremia and low back pain.
Residents Affected - Few
Review of her discharge MDS dated [DATE] revealed she required supervision with eating, activities of daily
living (ADL's), bed mobility and transfer.
Further review of her MDS revealed documentation of a planned discharge to the acute hospital.
Review of the progress notes for Resident #66 revealed she was discharged home with home health
services on 07/30/18.
During an interview on 10/25/18 at 8:52 A.M. with RN #700 verified the documentation regarding Resident
#66's planned discharge to the hospital was not accurate.
Based on resident record review and staff interview; the facility failed to accurately complete minimum data
set (MDS) assessments. This affected three (#36, #41 and #66 ) of 24 residents reviewed for accuracy of
the MDS. The census was 65.
Findings include:
1. Review of the medical record for Resident #36 revealed the resident was admitted to the facility on
[DATE]. Diagnoses included diabetes mellitus type two, bacteremia, complete traumatic amputation,
dermatitis, and chronic embolism and thrombosis.
Review of Resident #36's weight dated 03/11/18 revealed the resident's weight was 195.8 pounds. Review
of the weight dated 08/13/18 revealed Resident #36 was documented to weigh 234.4 pounds. Continued
review of Resident #36's weights revealed on 09/13/18 the resident weighed 234.8 pounds.
Review of a MDS assessment dated [DATE], section K 300, revealed Resident #36 was assessed to have
weight loss that was not prescribed.
Interview on 10/25/18 at 11:24 A.M. with clinical dietician #400 verified the MDS assessment dated [DATE]
for Resident #36, section K 300, was not accurate.
2. Review of the medical record for Resident #41 revealed the resident was admitted to the facility on
[DATE]. Diagnoses included osteoarthritis, paranoid schizophrenia, major depressive disorder,
hypothyroidism, obesity, and anxiety.
Review of Resident #41's medication administration record dated 09/2018, revealed the resident was
administered the hypnotic medication Ambien (zolpidem tartrate) on 09/13/18, 09/14/18, 09/15/18,
09/16/18, 09/17/18, 09/18/18, and 09/19/18.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365557
If continuation sheet
Page 7 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365557
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/25/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Maple Gardens Rehabilitiation and Nursing Center
515 South Maple Street
Eaton, OH 45320
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Review of an annual MDS assessment dated [DATE], revealed Resident #41 was assessed to have been
administered hypnotic medication five days during the seven day reference period.
Interview on 10/25/18 at 9:31 A.M. with Registered Nurse (RN) #700 revealed Resident #41 was
administered hypnotic medication on seven days of the seven day reference period. RN #700 verified the
annual MDS assessment dated [DATE] was inaccurate.
Event ID:
Facility ID:
365557
If continuation sheet
Page 8 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365557
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/25/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Maple Gardens Rehabilitiation and Nursing Center
515 South Maple Street
Eaton, OH 45320
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0679
Provide activities to meet all resident's needs.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, observation and interview the facility failed to develop and implement a
comprehensive and individualized activities program designed to meet the needs and the interests of
residents who were cognitively impaired. This affected one Resident (#15) of two reviewed for activities. The
facility census was 65.
Residents Affected - Few
Findings include:
Record review revealed Resident #15 was admitted on [DATE] to the facility. Diagnoses included intellectual
disabilities, bipolar disorder, anemia, dementia, schizoaffective disorder, Alzheimer's disease with early
onset, adult failure to thrive, and type 2 diabetes mellitus without complications. Resident #15's quarterly
assessment Minimum Data Set (MDS) dated [DATE] revealed the resident required extensive assistance for
bed mobility, transferring and bathing with severe impaired cognition.
Review of Resident #15's Care plan, dated 11/01/17 revealed staff will invite, encourage, remind and escort
resident to activity programs that promote exercise, socialization. Staff would involve Resident #15 in
activities which didn't depend on ability to communicate/hear, such as parties, crafts, movies. Staff will
engage Resident #15 in activities/tasks to keep occupied. Staff would modify activity settings to increase or
decrease stimulation as needed. Resident #15 had a short attention span and liked to wander through the
hallways but could find enjoyment in activities like music and entertainment. The care plan also indicated
Resident #15 loved Elvis songs and Elvis movies. She would participate in the parachute and ball toss at
times.
Review of Resident #15's 1:1 Participation Sheet revealed two 1:1 visits from activity in August 2018, no 1:1
visits from activity in September 2018 and no 1:1 visits from activity in October 2018.
Review of Resident 15's activity participation for the month of August 2018 revealed activity offered hand
and nail care 21 times and Resident #15 only participated one time. Further review revealed for social time,
Resident #15's participation was two times out of 26 times offered.
Review of Resident #15's activity participation for the month of September 2018 revealed activity offered
hand and nail care 22 times and Resident #15 did not participate at any time. Further review revealed for
social time, Resident #15's participation was zero out of 25 times offered.
Review of Resident#15's activity participation for the month of 10/01/18 through 10/25/18 revealed: activity
offered hand and nail care 15 times and Resident #15 did not participate at any time. Further review
revealed for social time, Resident #15's participation was zero of 22 times offered.
Observation on 10/22/18 at 11:32 A.M., revealed Resident #15 was in bed sleeping while activities was
going on.
Observation on 10/23/18 at 10:17 A.M., revealed Resident #15 was in bed with the television on.
Interview on 10/23/18 at 4:21 P.M. with Activity Aide (AA) #1 revealed Resident #15 had not been attending
activities offered. AA #1 reported Resident #15 was in bed until lunch time and typically watched television
in her room. AA #1 reported she was not able to watch Resident #15 and provide activities to the other
residents when there was not a State Tested Nursing Assistant (STNA) available
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365557
If continuation sheet
Page 9 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365557
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/25/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Maple Gardens Rehabilitiation and Nursing Center
515 South Maple Street
Eaton, OH 45320
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0679
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
to assist with Resident #15. AA #1 further reported Resident #15 could not stay seated long but enjoyed
socializing with other residents.
Interview on 10/23/18 at 5:00 P.M. STNA #1 stated Resident #15 gets into everything and is childlike.
Resident #15 needed assistance to get out of bed. STNA #1 reported Resident #15 enjoyed watching
television in her room.
Observation on 10/23/18 at 5:30 P.M., revealed Licensed Practical Nurse (LPN) #3 assisted Resident #15
with a transfer. Resident #15 was unable to get out of bed alone. LPN #3 assisted her out of bed by holding
out her hand and Resident #15 was able to ambulate and get out of bed with assistance.
Observation on 10/24/18 at 9:00 A.M., revealed Resident #15 was in bed with the television on.
Interview on 10/24/18 at 9:01 A.M., LPN #2 reported Resident #15 enjoyed watching cartoons in her room
and she was able to get out of the bed on her own.
Observation on 10/24/18 at 9:41 A.M., revealed Resident #15 was in bed while music and activity was
going on in the dining room.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365557
If continuation sheet
Page 10 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365557
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/25/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Maple Gardens Rehabilitiation and Nursing Center
515 South Maple Street
Eaton, OH 45320
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
resident record review and staff interview; the facility failed to complete weekly pressure ulcer assessments.
This affected one (#57) of one resident reviewed for pressure ulcers. The facility identified two residents
with pressure ulcers. The census was 65.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #57 revealed the resident was admitted to the facility on [DATE].
Diagnoses included paraplegia, osteomyelitis, cellulitis, tobacco use, chronic viral hepatitis C, mechanical
complications of cystostomy, colostomy status, anemia, atrial fibrillation, pressure ulcer of buttocks, chronic
obstructive pulmonary disease, protein calorie malnutrition, metabolic encephalopathy, cirrhosis of the liver,
anxiety, neuromuscular dysfunction of the bladder and gastrostomy.
Review of the care plan revision date 10/11/18 revealed Resident #57 had medial coccyx and and sacral
ulcers. Interventions included monitor/document the wound size, depth, margins, appearance, and
progress. Weekly treatment documentation was to include measurements (length, width, and depth), tissue
type, exudate, and any other notable changes or observations of each area of skin breakdown.
Review of the wound consultant documentation revealed Resident #57 was being assessed by the wound
consultant on a routine basis. The facility was lacking pressure ulcer assessments for the week of 08/05/18
to 08/11/18, 09/02/18 to 09/08/18, and 10/14/18 to 10/20/18. Review of the wound consultant progress note
dated 10/23/18 revealed, overall the three pressure wounds continued to improve. Measurements were
documented as right ischium four centimeters (cm) in length by five cm in width by one cm depth, left
ischium six and three tenths cm length by one and seven tenths cm length by four tenths cm depth, and
coccyx two and seven tenths cm length by nine cm width by six tenths cm depth.
Interview on 10/25/18 at 12:15 P.M. with the director of nursing (DON) revealed Resident #57's three
pressure wounds were to be assessed weekly. The DON verified there was no wound assessment
completed for the week of 08/05/18 to 08/11/18, 09/02/18 to 09/08/18, and 10/14/18 to 10/20/18.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365557
If continuation sheet
Page 11 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365557
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/25/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Maple Gardens Rehabilitiation and Nursing Center
515 South Maple Street
Eaton, OH 45320
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0770
Provide timely, quality laboratory services/tests to meet the needs of residents.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
resident record review, staff interview, and policy review; the facility failed to assess a physician ordered
amylase level. This affected one (#41) of five residents reviewed for unnecessary medication. The census
was 65.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #41 revealed the resident was admitted to the facility on [DATE].
Diagnoses included osteoarthritis, paranoid schizophrenia, major depressive disorder, hypothyroidism,
obesity, and anxiety.
Review of a physician order dated 08/03/18 revealed an order for the laboratory tests complete blood count,
hemoglobin A1C, liver panel, lipase, and amylase on 08/06/18.
Review of laboratory test results dated 08/06/18 revealed no assessment of Resident #41's amylase level.
Continued review of laboratory results for 08/2018, 09/2018, and 10/2018 revealed no documentation of the
residents amylase level.
Interview on 10/24/18 at 4:28 P.M. with the director of nursing (DON) verified the amylase laboratory test
was not completed for Resident #41.
Review of the facility policy titled, Request for Laboratory/Diagnostic Services revised 04/17, revealed
orders for diagnostic services will be promptly carried out as instructed by the physicians order.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365557
If continuation sheet
Page 12 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365557
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/25/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Maple Gardens Rehabilitiation and Nursing Center
515 South Maple Street
Eaton, OH 45320
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0804
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation and staff interview the facility failed to maintain safe food temperatures. This had the
potential to affected 64 residents. The facility identified Resident #60 as not consuming food by mouth. The
census was 65.
Residents Affected - Many
Findings include:
On 10/23/18 at 5:32 P.M., after all residents had been served, the temperature of the food was obtained
prior to making a test tray. The soup was 169 degrees, the pasta salad was 61 degrees and the chicken for
the crispy chicken salad was 69 degrees. The test tray was served at 5:40 P.M. and the temperature of the
soup was 157 degrees, the pasta salad was 62.6 degrees and the chicken was 69.4.
At the time of the observation, the Dietary Manager (DM) #1 was interviewed and verified the temperature
of the food was not safe. DM #1 verified the cold food should have been 41 degrees or lower.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365557
If continuation sheet
Page 13 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365557
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/25/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Maple Gardens Rehabilitiation and Nursing Center
515 South Maple Street
Eaton, OH 45320
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, staff interview, and facility policy review, the facility failed to safely store food items in
the snack nourishment refrigerators on each unit. This had the potential to affected 64 residents. The facility
identified Resident #60 as not consuming food by mouth. The census was 65.
Findings include:
Observation on 10/24/18 at 5:20 P.M., revealed Gardens I and Gardens II nourishment refrigerator had one
mighty shake date with an expiration date of 10/21/18, pumpkin cheese cake for a resident dated 10/21/18
with a use by date of 10/23/18, one 12 ounce (oz) can of Pepsi and a 1/2 bottle of 20 oz Mountain Dew
both with no name, two slices of cheese and two packs of crackers in a baggy unsealed with no date. At the
time of the observations, Licensed Practical Nurse (LPN) #300 was interviewed and verified the findings.
Observation on 10/24/18 at 5:30 P.M. revealed Meadow/Forest Rehab nourishment refrigerator had five
packs of crackers with two slices of cheese in a baggy unsealed with no date, a chocolate pudding cup
opened with no date, Thick and Easy honey thickener dated 10/19/18, a container of orange juice dated
10/15/18, and another container or orange juice dated 10/19/18 with a use by date 10/19/18. At the time of
the observations, Licensed Practical Nurse (LPN) #300 was interviewed and verified the findings. LPN #300
did not know if the
Review of the facility policy titled Food Receiving and Storage, revised July 2014, revealed all foods
belonging to residents must be labeled with the residents' name, the item and the use by date. Beverages
must be dated when opened and discarded after 24 hours. All foods stored in the refrigerator or freezer will
be covered, labeled and dated (use by date).
Review of the facility policy titled Foods Brought by Family /Visitors, revised February 2014, revealed
nursing staff is responsible for discarding perishable foods on or before the use by date. Perishable foods
must be stored in resealable containers with tightly fitting lids in the refrigerator. Containers will be labeled
with the resident's name, the item and the use by date.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365557
If continuation sheet
Page 14 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365557
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/25/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Maple Gardens Rehabilitiation and Nursing Center
515 South Maple Street
Eaton, OH 45320
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical review, observations, staff interview and review of census the facility failed to provide adequate
maintenance services to maintain residents room and the dining room on the 200 hall were in good repair.
This had the potential to affect 15 Residents (#7, #8, #10, #15, #19, #23, #25, #27, #37, #39, #47, #55,
#59, #61, and #215) who resided on the 200 hall. unit. The facility census was 65.
Findings include:
Observation on 10/22/18 at 10:35 A.M., room [ROOM NUMBER]-2 had several missing pieces of tile on the
floor that measured approximately 12 inches by 12 inches, next to the resident's bed. The subfloor was
observed to be exposed.
Observation on 10/22/18 at 11:00 A.M., revealed the common area next to room [ROOM NUMBER] and
across from the dining area had two holes in the wall near the floor which exposed the dry wall. The holes
were approximately 4 to 5 inches.
Observation on 10/22/18 at 11:00 A.M., revealed a 10-foot crack in the beam on the ceiling in the dining
room.
Interview on 10/24/18 at 9:42 A.M., Maintenance Supervisor (MS) #150 stated the dining room used to be
residents' rooms and was converted into the dining room. MS #150 stated he had fixed the crack in the
beam on the ceiling several times. MS #150 reported he did not have a maintenance repair slip for the
above issues. MS #150 revealed the facility did not have a policy on maintaining resident's rooms and
equipment. He indicated, rooms were prioritized by safety first. During the interview, MS #150 verified the
above findings.
Review of the census revealed 15 Residents (#7, #8, #10, #15, #19, #23, #25, #27, #37, #39, #47, #55,
#59, #61, and #215) resided on the 200 hall.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365557
If continuation sheet
Page 15 of 15
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Back to topCitations
16 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F679 - Activities
Provide activities to meet all resident's needs.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F770 - Laboratory Services
Provide timely, quality laboratory services/tests to meet the needs of residents.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
F761 - Labeling of Drugs and Biologicals
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
F914 - Be designed or equipped to assure full visual privacy for each
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
- 0211GeneralS&S Fpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0325GeneralS&S Epotential for harm
Have properly installed hallway dispensers for alcohol-based hand rub.
FAQ · About this visit
Common questions about this visit
What happened during the October 25, 2018 survey of MAPLE GARDENS REHABILITIATION AND NURSING CENTER?
This was a inspection survey of MAPLE GARDENS REHABILITIATION AND NURSING CENTER on October 25, 2018. The surveyor cited 16 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MAPLE GARDENS REHABILITIATION AND NURSING CENTER on October 25, 2018?
Yes, 16 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.