Inspection·January 16, 2025

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on observations, staff interviews, policy review and review of a facility emergency management plan, the facility failed to ensure there was an adequate amount of food available in the facility to account for scheduled meals and emergency situations. This had the potential to affect all 53 residents residing in the facility. Facility census was 53. Findings include: Tour of the facility kitchen with Dietary Supervisor #10 on 01/15/25 at 9:19 A.M. revealed the emergency food supply consisted of six cans (24 servings per can) of tuna; six cans (12 servings per can) of ravioli; 48 individual serving cans of a variety of soups; 72 orange juice, four ounces (oz) each; 12 packs of lemonade powder, each pack makes three gallons of lemonade; four five pound bags of dry milk; a box of crackers; and 150 gallons of water. Interview on 01/15/25 at 9:32 A.M. with Dietary Supervisor #10 confirmed, during the facility tour, the kitchen has a shelf with emergency food available that contains the items observed. Interview on 01/15/25 at 12:42 P.M. with Maintenance Director (MD) #32 confirmed he is responsible for the emergency water supply and there is currently 150 gallons of drinking water available. MD #32 confirmed Food Supplier #12 will supply water in an emergency, but recommends the facility has 1.5 gallons available for each resident on hand with a three-day supply, in case an emergency deliver is delayed. MD #32 also confirmed the facility has 53 residents, which would require 238.5 gallons to be on hand and the current supply is not enough to last three days. Interview on 01/15/25 at 1:30 P.M. with the Administrator confirmed the kitchen has an order placed for additional emergency food supplies coming on 01/16/25 from Food Supplier #12. Interview on 01/15/25 at 3:40 P.M. with Dietary Supervisor #10 confirmed the emergency food available at this time is not enough to last three days in the event of an emergency. Dietary Supervisor #10 confirmed the food currently available in the emergency stock would not last three days for the 51 residents in house, who eat food from the kitchen. Interview on 01/16/25 at 10:43 A.M. with Dietary Supervisor #10 confirmed the Disaster Plan, undated states the facility will have a three-day supply of staple goods on hand at all times and that disposable eating ware in ample supply will be available. Dietary Supervisor #10 confirmed the facility does not have the three-day supply of staple goods on hand and does not have enough disposable eating ware. Dietary Supervisor #10 also confirmed an order for the disposable eating ware has been (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 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 01/16/2025 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)