F 0569
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Level of Harm - Minimal harm
or potential for actual harm
Based on medical record review and staff interview, the facility failed to ensure money from a resident fund
account (RFA) was returned in a timely manner following the resident's discharge. This affected one (#60)
out of the three residents reviewed for resident fund accounts. The facility census was 52.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #60 revealed an admission date of 05/01/23 with medical
diagnoses of schizophrenia, chronic obstructive pulmonary disease, asthma, hypertension, and anemia.
Review of the medical record for Resident #60 revealed a discharge date of 11/20/23.
Review of the medical record for Resident #60 revealed a quarterly Minimum Data Set (MDS) assessment,
dated 09/07/23, which indicated Resident #60 had moderate cognitive impairment and required supervision
with toileting, bathing, bed mobility and transfers.
Review of the RFA statement for Resident #60 revealed a balance of $50.87 on 12/01/23. Review of the
RFA statement revealed the balance was refunded to Resident #60 on 02/09/24 and the RFA was closed.
Interview on 11/05/24 at 1:08 P.M. with Business Office Manager (BOM) #215 confirmed Resident #60 was
discharged from the facility on 11/20/23 and the resident's RFA remaining balance was not disbursed until
02/09/24. BOM #215 confirmed Resident #60 had transferred to another facility where she remained as a
resident for at least six weeks after discharge. BOM #215 stated the facility did not have a policy for RFA.
This deficiency represents non-compliance investigated under Complaint Number OH00158172.
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
11/05/2024
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure
staff followed infection control procedures during medication administration. This affected one (#51) out of
the two residents observed for medication administration. The facility census was 52.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #51 revealed an admission date of 02/27/23 with medical
diagnoses of Parkinson's disease, arthritis, hypertension, anxiety, heart failure, and depression.
Review of the medical record for Resident #51 revealed a quarterly Minimum Data Set (MDS) assessment,
dated 08/24/24, which indicated Resident #51 had moderate cognitive impairment and was independent
with eating and bed mobility, required supervision with toileting and transfers, and required partial/moderate
staff assistance with bathing.
Review of the medical record for Resident #51 revealed a physician order dated 02/27/23 for
Carbidopa-Levodopa 25-100 milligram (mg) one tablet by mouth four times per day, an order dated
02/28/23 for glucosamine 400 mg one tablet by mouth daily and Primidone 50 mg one tablet by mouth
three times per day, an order dated 10/11/24 for Buspar 5 mg one tablet by mouth three times per day, an
order dated 01/07/24 for hydroxyzine 25 mg one tablet by mouth two times per day, and an order dated
02/06/24 for Coreg 3.125 mg one tablet by mouth two times per day.
Observation on 11/05/24 at 8:25 A.M. revealed Registered Nurse (RN) # 202 prepare Resident #51
medications for administration. The observation revealed RN #202 place carbidopa-levodopa, glucosamine,
Primidone, Buspar, hydroxyzine, and Coreg tablets into his bare hands prior to placing medications into a
medication cup. The observation revealed RN #202 observed Resident #51 consume the medications.
Interview on 11/05/24 at 9:06 A.M. with RN #202 confirmed he had not performed hand hygiene before or
after medication administration and that he placed Resident #51's medications into his bare hands prior to
administration.
Review of the facility policy titled, Medication Administration, stated only persons licensed by the State to
prepare, administer and document the administration of medications may do so. The policy stated the
medications must be administered in accordance with the orders, including any required time frame. The
policy also stated staff shall follow established facility infection control procedures (i.e. handwashing,
antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications as applicable.
The deficiency was based on incidental findings discovered during the course of this complaint
investigation.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365557
If continuation sheet
Page 2 of 2
