Inspection·December 12, 2019

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few transferring, dressing, and toilet use tasks. She was able to feed herself with supervision. The MDS also revealed the resident used tobacco. Due to the resident's severe visual impairment, she was evaluated by an ophthalmologist on 11/15/19 and again on 12/05/19, for blurry vision and possible cataracts. At the 12/05/19 evaluation, the physician made a referral for the resident to be evaluated by a retinal specialist for vitreous hemorrhage of the right eye and proliferating diabetic retinopathy (PDR). On 12/10/19, during the survey, the resident was evaluated by the retinal eye specialist. She was administered eye injections to treat the PDR and was scheduled for eye surgery. Review of the resident's care plans, revealed no care plan was developed to address the resident's vision losses and visual needs. The lack of a care plan to address vision needs, was confirmed by the DON on 12/11/19 at 1:00 P.M. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365557 If continuation sheet Page 2 of 8 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 12/12/2019 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff and resident interview, the facility failed to ensure appropriate interventions were in place to prevent the development of a vascular ulcer. This affected one (#39) of two residents reviewed for non-pressure related skin conditions. Facility census was 61 residents. Residents Affected - Few Findings include: Review of Resident #39's record, revealed she was admitted to the facility on [DATE], with diagnoses including neurogenic arthritis, type 2 diabetes, hypertension, nephrotic syndrome, edema, severe protein caloric malnutrition, visual loss, chronic kidney disease with dialysis, and peripheral vascular disease. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed the resident participated in a Brief Interview for Mental Status (BIMS) with a score of 15, fully intact cognitive abilities. The MDS revealed the resident had severe vision impairment and required extensive assistance of staff with bed mobility, transferring, dressing, and toilet use tasks. She was able to feed herself with supervision. The MDS also revealed the resident used tobacco and had no pressure sores. On 10/24/19 a care plan was developed that documented the resident was at risk for skin breakdown related to diabetes, malnutrition, weakness, impaired mobility, and chronic kidney failure. Interventions included to apply lotion/moisture barrier cream as needed, observe skin for redness or open areas and notify the nurse, and provide a skin assessment as needed. Further review of the care plan revealed there were no interventions in place to prevent pressure sores or vascular ulcers to the lower extremities including applying skin prep to the heels, the use of compression stockings, elevating the lower extremities, or applying pressure relief boots. Review of the facility's skin assessment dated [DATE], revealed the resident's skin was intact with no signs of breakdown. The nurse documented on 12/09/2019 at 8:00 A.M., while skin prepping the resident's right ankle, she stated that she really doesn't understand why the nurses skin prep her ankle when her heal was hurting. Her sock was taken off and an area was noted to her right heel. Contacted the supervisor. The supervisor will follow up. Review of the skin assessment dated [DATE], revealed the resident had a 2.0 by 2.0 vascular ulcer on her right heel. The measurements did not designate whether centimeters (cm) or inches. On 12/10/2019 at 10:01 A.M., the nurse documented the skin assessment completed today. Resident has a suspected vascular ulcer to right heel. New orders to apply skin prep, apply heel boot while in bed, and a vascular study to both legs. Resident is aware of new orders. Will continue to monitor. On 12/11/19 at 11:50 A.M., the resident was interviewed and stated she was going to have a doppler on her right foot today. She stated the staff told her the open area on her heel was the size of a quarter. She gave permission for the surveyor to observe the procedure. The technician arrived to the facility and performed the ultrasound. The resident's lower extremities from the mid-shin down, were observed to be reddened and swollen. The resident's right medial heel, was observed to have a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365557 If continuation sheet Page 3 of 8 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 12/12/2019 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 0684 purplish/red surface ulcer approximately 2.0 cm by 3.0 cm in diameter with no depth. Level of Harm - Minimal harm or potential for actual harm On 12/11/19 at 1:00 P.M., the Director of Nursing (DON) confirmed there were no preventive measures in place to prevent this at risk resident from developing pressure or vascular ulcers on her lower extremities until after an ulcer developed on her right outer heel. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365557 If continuation sheet Page 4 of 8 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 12/12/2019 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff and resident interviews and policy review, the facility failed to ensure residents implemented the facility policy regarding smoking. This affected two (#39 and #40) out of 20 residents residing in the facility who were identified as smoking tobacco. Facility census of 61 residents. Findings include: 1. Review of Resident #39's record, revealed she was admitted to the facility on [DATE], with diagnoses including neurogenic arthritis, type 2 diabetes, hypertension, nephrotic syndrome, edema, severe protein caloric malnutrition, visual loss, chronic kidney disease with dialysis, and peripheral vascular disease. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed the resident participated in a Brief Interview for Mental Status (BIMS) with a score of 15, fully intact cognitive abilities. The MDS revealed the resident had severe vision impairment and required extensive assistance of staff with bed mobility, transferring, dressing, and toilet use tasks. She was able to feed herself with supervision. The MDS also revealed the resident used tobacco. Review of the Smoking Safety Screen dated 11/14/19, revealed the resident did not have cognitive deficits but had visual impairment. She had no dexterity problems and was able to light her own cigarettes. The resident did need facility to store lighter and cigarettes. Resident was alert and oriented and she was able to safely smoke unsupervised. Resident had been educated on the facility's smoking policy and dangers of smoking around oxygen. Review of the care plan dated 11/14/19, revealed the resident was a current, everyday smoker. The resident had been made aware of and signed the safe smoking policy. She had been made aware of the dangers of smoking around or with oxygen on. Based on the smoking assessment, the resident was safe to smoke unsupervised. At times the resident was non-compliant with the policy of keeping smoking materials at the nurse's station. She was not interested in smoking cessation. Interventions included educating on smoking safety as needed, providing education on the safety of not smoking around oxygen as needed, and providing with education on smoking cessation. The resident signed the facility's Safe Smoking Policy on 11/11/19. The policy document, all residents and or patients, who currently smoke, commence smoking, have significant change of condition, or practice unsafe smoking will be assessed to determine if they are appropriate to smoke with supervision or independently. Protective material will be available if assessment requires such. Supervised smoking times will not exceed 15 minutes. Independent smokers are not required to have staff supervision while in the designated area. Independent smokers; assessments will determine if a resident is safe to smoke independently with still following some of the required guidelines as supervised residents. Smoking materials will be kept at nursing stations. No resident shall have any cigarettes or lighters in their possession while inside the building unless on their way out to smoke. Independent smokers may sign out in the Leave of Absence book at their nurses' station where they reside and then request their smoking materials to take with them. Residents are advised that if any smoking material is found in their possession, that smoking privileges will be revoked. The smoking policy is part of the admission agreement and must be signed and undergo an evaluation prior to being able to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365557 If continuation sheet Page 5 of 8 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 12/12/2019 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 0689 Level of Harm - Minimal harm or potential for actual harm attend smoke breaks. Any non-compliance with smoking policy will be addressed with the resident and family members and the safe smoking assessment will be reviewed and updated. Additionally, smoking in non-designated areas may warrant a 30 day day discharge notice for violation of all resident's and staff's safety. This resident has received and understands the safe smoking policy of this facility. This resident also understands the policy is effective immediately. Residents Affected - Few On 12/09/19 at 2:00 P.M., the resident was observed outdoors smoking with other residents. The resident was carrying her own cigarettes and lighter on her person. The resident stated she kept her cigarettes and lighter in her room. On 12/09/19 at 3:43 P.M., the resident was observed carrying her own cigarettes and lighter in her room. The resident stated, they better not try to take them away. During interview with the Director of Nursing (DON) on 12/10/19 at 2:05 P.M., she stated there are some residents who are carrying their cigarettes and lighter on their persons and who don't hand in their lighters and cigarettes to the nurse for safekeeping as stated in the smoking policy. She stated the residents were independent smokers and it is very hard to prevent them from carrying smoking materials on their person. 2. Medical record review for Resident #40 revealed an admission date of 09/11/18. Medical diagnoses included heart failure, renal failure, diabetes and chronic obstructive pulmonary disease (COPD) Review of quarterly Minimum Data Set (MDS) dated [DATE] for Resident #40 revealed she was cognitively intact. Functional status was extensive assistance for bed mobility, transfers, and toilet use. She was supervision for eating. Review of care plan dated 04/02/19 for Resident #40 revealed she was a smoker and based on assessment she was safe to smoke unsupervised and had been educated on the dangers of smoking with oxygen on and around oxygen. Interventions were to educate on smoking safety and on dangers of not smoking around oxygen and to provide the resident with education related to smoking cessation. Review of physician orders dated 10/17/19 for Resident #40 revealed oxygen at two liters per minute via nasal cannula. Review of smoking assessment dated [DATE] for Resident #40 revealed she was safe to smoke with supervision. The assessment further revealed resident needed to be taken outside to smoke with assistance and brought back in because she had trouble holding the cigarette. She also had trouble taking self to and from outdoors in her wheelchair. Interview with Resident #40 on 12/09/19 at 3:10 P.M. revealed she started smoking again in April 2019. She revealed she takes her cigarettes and lighter outside with her to smoke and keeps them in her room with her. She stated she was an independent smoker and could go outside with her smoking materials but didn't know what the policy was regarding keeping smoking materials in her room with her. Observation at the same time as the interview revealed she had a pack with four cigarettes in the package and a lighter in her coat pocket in her room. Interview with Licensed Practical Nurse (LPN) #77 on 12/09/19 at 3:30 P.M. revealed the residents are supposed to get the cigarettes and lighter from the locked cabinet behind the nursing station when they wanted to smoke. She revealed even if a resident was unsupervised they still had to keep the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365557 If continuation sheet Page 6 of 8 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 12/12/2019 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 0689 smoking materials at the locked box at the nursing station. Level of Harm - Minimal harm or potential for actual harm Interview with LPN #15 on 12/09/19 at 3:21 P.M. verified the resident had a pack of four cigarettes and a lighter in her pocket of her coat in her room. She stated it is a continuous education with the residents to keep the smoking materials at the nursing station. She stated this resident has been non-compliant with placing her smoking materials back in the locked box. Residents Affected - Few Interview with the DON on 12/11/19 at 2:00 P.M. revealed the smoking assessment should have been updated due to there was one instance when the resident was outside smoking and was acting drowsy and tired and couldn't hold on to her cigarette, so she told the nurse to make sure she went outside with someone. Review of the facilities undated policy titled Safe Smoking Policy revealed the policy was intended to ensure that all residents who reside at the facility remain safe from any harm associated with smoking practices for example cigarette burns, smoke inhalation and fire. The policy revealed smoking materials will be kept at the nursing stations. There shall be no resident to have any cigarettes or lighters in their possession while outside the building unless on their way out to smoke. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365557 If continuation sheet Page 7 of 8 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 12/12/2019 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. Based on observation and staff interview, the facility failed to ensure five bathroom floors were clean. This has the potential to affect five (#11, #19, #45, #37 and #14) out of 24 residents reviewed during the annual survey. The census was 61. Findings included: Observation of Resident #11's bathroom on 12/09/19 at 10:17 A.M. revealed the floor was badly stained and around the bottom of the toilet there was a dark thick substance and the floor was sticky. Observation on 12/09/19 at 11:25 A.M. of Resident #19's bathroom revealed the tile was discolored. Observation of Resident #45's bathroom floor on 12/09/19 at 12:06 P.M. revealed it was badly stained under the sink and around and behind the toilet. Observation on 12/09/19 at 2:27 P.M. of Resident #37's and #14's shared bathroom revealed under the sink there were dark stains. Observation with the Administrator and Housekeeping Supervisor (HS) #41 on 12/12/19 at 1:55 P.M. verified the conditions of the above mentioned bathrooms for Resident #11, #19, #45, #37 and #14. Interview with the Administrator on 12/12/19 at 2:00 P.M. verified he thought it was an issue of the bathroom floors but more of a scrubbing and a waxing that was needed and said the facility just got remodeled in the front of the facility and had plans to remodel the rest of the rooms, but didn't have a date. Interview with HS #41 on 12/12/19 P.M. verified the bathroom floors in the above mentioned rooms needed scrubbed and waxed. He stated the census was low and he haven't been able to get to them in quite a while now. He denied he had documentation of the last time the bathrooms had been scrubbed and waxed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365557 If continuation sheet Page 8 of 8