Health inspection·April 17, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, review of an invoice from an outside plumbing company, review of maintenance temperature logs, and staff interview, the facility failed to ensure hot water temperatures were maintained between 105 degrees Fahrenheit (F.) and 120 degrees F. as required and did not pose a potential burn risk for the residents. This had the potential to affect seven residents (#2, #7, #10, #18, #20, #21, and #26), who the facility identified as having the use of the first floor shower room and five residents (#8, #9, #22, #25, and #28), who the facility identified as having the ability to utilize the sinks in their rooms on the second floor, without staff assistance. Findings include: On 04/17/25 at 9:20 A.M., an observation of the facility's boiler room located in the basement revealed there were three hot water tanks for providing hot water throughout the facility. Two of the three hot water tanks were of the same size and were a standard electric water heater. The third hot water tank was larger in size and was a hybrid energy efficient hot water tank with a display screen on the top of it that indicated what the temperature of the hot water was inside the tank and what operating set up temperature was. The tank temperature was indicated to be 125 degrees F. on the display screen and the operating set up temperature was also 125 degrees F. On 04/17/25 at 9:44 A.M., hot water temperature readings were obtained from various areas of the facility, as there had been concerns about the facility's hot water being too cold for residents during their showers. Temperatures of the hot water was checked on both the first floor and the second floor. The temperatures were obtained from the resident rooms on both ends of the hall and from the shower rooms on each floor that were centrally located on each hall. The first floor was noted to have hot water temperatures that exceeded 120 degrees F. in room [ROOM NUMBER] and room [ROOM NUMBER]. room [ROOM NUMBER] was noted to have a hot water temperature from the sink in the residents' room at 133 degrees F. room [ROOM NUMBER] was noted to have hot water from the sink at 129.7 degrees F. The shower room on the first floor located in the middle of the hall was noted to have a hot water temperature from the sink at 136.2 degrees F. On 04/17/25 at 10:04 A.M., hot water readings were obtained from the second floor, again testing rooms on each end of the hall and in the centrally located shower room. The hot water temperature in room [ROOM NUMBER] was noted to be 126.3 degrees F. and room [ROOM NUMBER] was 129 degrees F. The shower room on the second floor had a hot water temperature reading of 114.8 degrees F, which fell within the required temperature ranges for hot water. Findings were verified by Maintenance Director #100 at the time of the observations. (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: 366139 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 366139 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Hills Skilled Nursing & Rehabilitation 31054 State Route 93 North McArthur, OH 45651 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)