Maple Gardens Rehabilitiation and Nursing Center

Inspectors wroteBased on record review, review of Self-Reported Incidents (SRI), interviews and facility policy review, the facility failed to ensure supervision was provided during smoke break which resulted in resident to resident abuse. This affected one resident (Resident #30) of three reviewed for abuse. The facility census was 63. Review of the medical record revealed Resident #3 had an admission date of 08/31/21 with diagnoses of alcohol induced persisting dementia. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 was cognitively intact. Resident #3 did not exhibit physical or verbal behaviors. Review of the Smoking Safety Screen dated 05/05/26 revealed Resident #3 was safe to smoke with supervision. Review of the care plan revealed Resident #3 had behavior problem related to being verbally abusive to roommate and others and loud w/ staff at times. [...]

Inspectors wroteBased on medical record review, interview, and policy review, the facility failed to maintain complete and accurate documentation. This affected one (#64) out of three residents reviewed for documentation. The facility census was 61.

Inspectors wroteBased on medical record review, observation, interview, review of training competency records, review of the manufacturers guidelines, facility record review, policy review, and review of current Occupational Safety and Health Administration (OSHA) guidance, the facility failed to ensure glucometers were cleaned after use. This affected one (Resident #60) out of two residents observed for glucometer use. In addition, the facility failed to maintain documentation of annual fit testing for staff for a respirator required for respiratory protection when working with Coronavirus Disease 2019 (COVID-19) positive residents. This had the potential to affect all 64 residents who resided in the facility. The facility census was 64.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure two of four medication carts were locked when not within the line of sight of facility staff. This had the potential to affect all 64 residents who resided in the facility. The facility census was 64. Findings Included:During an observation and concurrent interview on 02/25/26 at 6:01 A.M., at the nurse's station on the 300 Hall, a medication cart and a treatment cart, located between the Minimum Data Set (MDS) office and the nursing station, were observed unlocked. There were no staff members in the hallway where the carts were located. Three staff were observed in an adjacent hallway walking away from the carts. At 6:08 A.M., Licensed Practical Nurse (LPN) #01 returned to the nursing station. LPN #01 stated the carts should have been locked when not in use. [...]

Inspectors wroteBased on medical record review, observation, resident and staff interview, and facility policy review, the facility failed to ensure foods were served per resident preference. This affected one (Resident #44) out of five residents reviewed for food preferences. The facility census was 64.

Inspectors wroteBased 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.

Inspectors wroteBased on medical record reviews, review of a facility self-reported incident (SRI), staff and legal guardian interviews, and policy review, the facility failed to implement their abuse policy by ensuring a resident's legal guardian and physician were notified of an allegation of potential sexual abuse. This affected one (#12) out of the three residents reviewed for abuse. The facility census was 53.

Inspectors wroteBased on review of the medical record reviews, review of a facility self-reported incident (SRI), staff interviews, and policy review, the facility failed to report an allegation of potential sexual abuse to the Ohio Department of Health in a timely manner. This affected one (12) out of the three residents reviewed for abuse. The facility census was 53.

Inspectors wroteBased on medical record reviews, review of a facility self-reported incident (SRI), staff interview, and policy review, the facility failed to ensure staff intervened when a concern was identified regarding potential resident to resident sexual abuse. The affected one (#12) out of three residents reviewed for abuse. The facility census was 53.

Inspectors wroteBased on medical record review, staff and resident interviews, and review of the Resident Assessment Instrument (RAI) 3.0 manual, the facility failed to ensure a comprehensive person-centered care plan was updated with current interventions. This affected one (#51) out of the three residents reviewed. The facility census was 53.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to ensure staff wore hairnets and gloves while serving meals. This affected all residents except Resident #46 who was nothing by mouth (NPO) and did not receive food from the kitchen. Census was 66.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure resident care plans were developed to address the resident's care needs. This affected two (#14 and #39) out of 15 sampled residents for care plans. Facility census was 61 residents.

Inspectors wroteBased 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.

Inspectors wroteBased 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.