Inspection·March 30, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to create a comprehensive care plan for a resident with a diagnosis of post-traumatic stress disorder (PTSD). This affected one resident (#215) out of twenty-one residents reviewed for care plans. The facility census was 66. Findings included: Review of the medical record for Resident #215 revealed an admission date of 02/01/23. Diagnoses included, but not limited to, PTSD, Parkinson's Disease, chronic obstructive pulmonary disease (COPD), vascular dementia, history of Coronavirus (COVID-19), and hypertension. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] for Resident #215, revealed the resident had an intact cognition. The resident had a Brief Interview for Mental Status (BIMS) assessment score of 15 which indicated intact cognition. Assessment indicated the resident had no hallucinations, delusions, behaviors or concerns with his mood and /or rejection of care. Review of the progress note dated 02/08/23 at 6:50 P.M. for Resident #215, revealed the resident was in his room on the phone. The nurse entered the resident's room, and the resident handed the nurse the phone. Resident #215 had called the Veteran Crisis Center. The Crisis Center stated that the resident had called them and stated he wanted to commit suicide and planned to hang himself. Resident #215 was sent to the hospital for evaluation and treatment. Review of the progress note dated 02/28/23 at 2:31 P.M for Resident #215, revealed a referral was sent to the facility counseling service after a consent was received from the resident. Review of the care plans for Resident #215 revealed no care plan was implemented for the resident's diagnosis of PTSD. Interview on 03/08/23 at 9:37 A.M. with the Director of Nursing (DON), confirmed Resident #215 did not have a care plan for his diagnosis of PTSD. The DON stated that the resident had a long-standing history of suicidal and homicidal ideations. Review of the facility policy titled Care Plans, Comprehensive Person-Centered dated 12/01/16 revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. 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 2 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 03/30/2023 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)