Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Maple Gardens Rehabilitiation And Nursing Center during CMS and state inspections, most recent first.
A resident with DM had a fingerstick blood glucose check performed by an LPN, but the used glucometer was placed back into the medication cart without being cleaned first. The ADON/IP and DON stated glucometers were expected to be cleaned and disinfected after each use, and another LPN said the staff member had been trained on the cleaning procedure. The facility also did not have documentation showing annual respirator fit testing for staff, although multiple employees stated they had been fit tested in 2025.
Unlocked Medication and Treatment Carts: Two of four carts were observed unlocked at the nurse's station area when no staff were in the hallway and the carts were not within staff line of sight. An LPN stated the carts should have been locked when not in use, while the ADON/IP and DON stated medication carts were expected to be locked when not supervised. The unlocked medication cart contained lisinopril, amlodipine, and glipizide, and facility policy required drug and biological storage compartments to be locked when not in use.
A resident with multiple chronic conditions, including PCM, cirrhosis, DM2, GERD, and FTT, had a documented dislike for beans, but beans were still served on a lunch tray despite the preference being listed for staff. The CNA said she checked the tray ticket for the correct diet but missed the dislike, and the DM confirmed the resident should have received an alternative vegetable instead of beans. Interviews with the RD, Administrator, and regional clinical leader confirmed that food preferences were expected to be communicated on tray tickets and honored.
The facility was found to have an inadequate emergency food and water supply, failing to meet the requirements outlined in its Disaster Plan. Observations revealed insufficient quantities of staple goods, perishable goods, and water to last three days for all 53 residents. Interviews confirmed the deficiency, highlighting the need for a three-day supply of essentials, which was not met at the time of the survey.
A facility failed to notify a resident's legal guardian and physician of a potential sexual abuse allegation. The incident involved a non-ambulatory resident with multiple medical conditions and moderate cognitive impairment, and another resident who was found in a compromising position in her room. Despite the suspicious circumstances, the non-ambulatory resident denied inappropriate contact. The facility did not document the incident or notify the guardian and physician as required by policy.
A facility failed to report an allegation of potential sexual abuse to the Ohio Department of Health within the required timeframe. The incident involved a non-ambulatory resident with multiple medical conditions and moderate cognitive impairment, and another resident who was cognitively intact. The latter was found in a suspicious situation in the non-ambulatory resident's room. Despite immediate internal actions, the facility delayed reporting the incident to the authorities.
A facility failed to intervene appropriately in a potential resident-to-resident sexual abuse incident. A resident with cognitive impairment was found in a compromising situation with another resident, who was cognitively intact. The incident was not reported immediately, and the facility's response was delayed, leading to a deficiency finding.
A facility failed to update a comprehensive care plan for a resident with behavioral concerns after an incident involving inappropriate behavior. Despite implementing 15-minute checks and one-on-one supervision, the care plan did not reflect these interventions, as confirmed by staff interviews. The oversight was identified during a complaint investigation, indicating non-compliance with care planning regulations.
A facility failed to promptly return funds from a resident fund account after a resident's discharge. The resident, with multiple medical conditions, was discharged and transferred to another facility, but their RFA balance was not refunded for several months. The Business Office Manager confirmed the delay and the absence of a policy for RFAs.
A registered nurse in an LTC facility failed to follow infection control procedures during medication administration for a resident with multiple medical conditions. The nurse did not perform hand hygiene and handled medications with bare hands, contrary to facility policy. This incident was identified during a complaint investigation.
Glucometer Cleaning and Respirator Fit Testing Documentation
Penalty
Summary
The facility failed to ensure that a glucometer was cleaned after use during a blood glucose check for a resident with type 2 diabetes mellitus. Resident #60 was admitted on 03/07/25 and had a care plan directing staff to monitor blood sugar levels. During an observed medication pass on 02/25/26 at 6:16 A.M., an LPN performed a fingerstick blood glucose test with a result of 144 mg/dL, then placed the used glucometer on the medication cart, removed gloves, performed hand hygiene, documented the result, and placed the glucometer into the top drawer of the cart without cleaning it first. The LPN stated she had not been told she had to clean the glucometer. The ADON, who also served as the IP, stated that multiuse equipment, including glucometers, was expected to be cleaned and disinfected after each use. Another LPN stated she had trained the LPN involved on how to complete a fingerstick glucose check, clean the glucometer, and review the cleaning procedure, and said the LPN had demonstrated competency during training. The DON stated glucometers were expected to be cleaned per the manufacturer's instructions and said re-education had been provided to the LPN following the observation. The facility also failed to maintain documentation of annual fit testing for staff required for respiratory protection when working with COVID-19 positive residents. An undated nursing phone roster listed 80 current employees, and multiple staff members from nursing, dietary, admissions, and housekeeping stated during interviews that they had been fit tested in 2025. However, the ADON/IP stated she and CS/MR #05 were responsible for fit testing and that documentation should be maintained, but she found no documentation for 2025. The DON stated the roster was a current list of employees and that fit testing documentation was expected to be maintained and readily available.
Unlocked Medication and Treatment Carts
Penalty
Summary
The facility failed to ensure that two of four medication carts were locked when not within the line of sight of facility staff. 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 MDS office and the nursing station were observed unlocked while no staff members were in the hallway where the carts were located. Three staff were seen in an adjacent hallway walking away from the carts. At 6:08 A.M., LPN #01 returned to the nursing station and stated the carts should have been locked when not in use. The unlocked medication cart contained lisinopril, amlodipine, and glipizide. During interviews on 02/27/26, the ADON/Infection Preventionist stated she expected medication carts to always be locked when not in use, and the DON stated she expected medication carts to be locked if the nurse could not see the drawers and supervise the cart. Facility policy titled, Storage of Medications, revised April 2007, stated that compartments containing drugs and biologicals shall be locked when not in use and that trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.
Resident Food Preferences Not Honored
Penalty
Summary
The facility failed to ensure foods were served according to resident preference for Resident #44, who was admitted with diagnoses including hyperlipidemia, GERD, adult failure to thrive, atherosclerotic heart disease, ascites, depression, protein calorie malnutrition, cirrhosis of the liver, and type 2 diabetes mellitus. The resident had a BIMS score of 15 and was able to eat independently after tray setup. The record and interviews showed the resident had identified beans as a disliked food, and that preference was supposed to be reflected on the tray ticket and honored by staff. During interview and observation, Resident #44 stated beans were sometimes served despite the dislike being known, and on one observed lunch tray the resident was served baked beans and did not eat them. The CNA who delivered the tray said she checked the tray ticket for the correct diet but did not notice the dislike for beans and should have offered an alternative. The Dietary Manager stated the resident should have received a different vegetable, such as double carrots, instead of beans, and that beans may have been served because staff did not pay attention to the tray ticket. The Registered Dietitian, Administrator, and Regional Director of Clinical Operations all stated resident food preferences should be communicated, listed on the tray ticket, and honored. The facility policy required food preferences to be assessed on admission and offered a variety of foods, and stated that if a resident was unhappy with the diet, staff would create a care plan the resident was satisfied with.
Inadequate Emergency Food and Water Supply
Penalty
Summary
The facility failed to maintain an adequate emergency food and water supply, which is necessary to ensure the well-being of all 53 residents during emergencies. During a tour of the facility's kitchen, it was observed that the emergency food supply was insufficient, consisting of limited quantities of tuna, ravioli, soups, orange juice, lemonade powder, dry milk, crackers, and water. Interviews with the Dietary Supervisor and Maintenance Director confirmed that the current stock would not last the required three days in an emergency, as outlined in the facility's Disaster Plan. The plan mandates a three-day supply of staple goods and a two-day supply of perishable goods, along with ample disposable eating ware, none of which were adequately stocked. The Maintenance Director acknowledged that the facility had only 150 gallons of water available, which is below the recommended 238.5 gallons needed for the 53 residents over three days. The facility's Disaster Plan and Food Supplier's Emergency Preparedness Plan both emphasize the necessity of having contingency plans and sufficient supplies on hand. Despite an order being placed for additional emergency food supplies and disposable eating ware, the deficiency was noted due to the current lack of compliance with the facility's own emergency preparedness guidelines.
Failure to Notify Guardian and Physician of Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse policy by not notifying a resident's legal guardian and physician of an allegation of potential sexual abuse. This incident involved a resident with multiple medical diagnoses, including multiple sclerosis, COPD, dementia, depression, and peripheral vascular disease, who was non-ambulatory and had moderate cognitive impairment. The incident occurred when another resident, who was cognitively intact and independent in most activities of daily living, was found in the non-ambulatory resident's room in a compromising position. The incident was reported by a State tested Nursing Assistant (STNA) who witnessed the cognitively intact resident in the non-ambulatory resident's room with his pants partially down. The STNA immediately informed a Registered Nurse (RN) of the situation. The RN, upon entering the room, found the cognitively intact resident sitting in his wheelchair and observed the non-ambulatory resident's brief to be loose. Despite the suspicious circumstances, the non-ambulatory resident denied any inappropriate contact and stated she felt safe but did not want the other resident to enter her room again. The Director of Nursing (DON) and the facility Administrator were notified of the incident, and an investigation was initiated. However, the facility did not document the incident in the non-ambulatory resident's medical record, nor did they notify her legal guardian or physician until several days later. The facility's policy required such notifications and documentation, which were not adhered to, leading to the deficiency.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of potential sexual abuse to the Ohio Department of Health in a timely manner, affecting one of the three residents reviewed for abuse. The incident involved a resident with multiple medical diagnoses, including multiple sclerosis, COPD, dementia, depression, and peripheral vascular disease, who was non-ambulatory and had moderate cognitive impairment. Another resident, who was cognitively intact and independent in most activities of daily living, was found in the non-ambulatory resident's room in a suspicious situation. A State Tested Nursing Assistant (STNA) witnessed the cognitively intact resident in a compromising position and reported the incident to a Registered Nurse (RN). The RN, upon being informed, took immediate action by removing the resident from the room and assessing the situation. The RN and the facility's Administrator both interviewed the non-ambulatory resident, who denied any inappropriate contact but expressed a desire not to have the other resident enter her room again. Despite the suspicious nature of the incident, the facility did not report the allegation to the Ohio Department of Health until five days later, which was beyond the 24-hour reporting requirement as per the facility's policy on abuse, neglect, exploitation, and misappropriation of resident property.
Failure to Intervene in Potential Resident-to-Resident Abuse
Penalty
Summary
The facility failed to appropriately intervene in a situation involving potential resident-to-resident sexual abuse. Resident #12, who had multiple medical diagnoses including moderate cognitive impairment and was non-ambulatory, was allegedly involved in an incident with Resident #51. Resident #51, who was cognitively intact and independent in most activities of daily living, was found in Resident #12's room in a compromising position by a State tested Nursing Assistant (STNA) #115. The STNA observed Resident #51 on top of Resident #12's bed with his pants partially down and was instructed by Resident #51 not to disclose the incident. Following the incident, STNA #115 left Resident #12 alone with Resident #51 to seek assistance from other staff members. Registered Nurse (RN) #166 was informed of the situation and upon entering the room, found Resident #51 in a wheelchair and covering Resident #12 with a sheet. Despite Resident #12 denying any inappropriate contact, RN #166 noted the looseness of Resident #12's brief and reported the incident to the Director of Nursing (DON). The facility's Administrator was also notified and conducted interviews with the involved parties, confirming that the incident was suspicious but that Resident #12 felt safe and denied any assault. The facility's policy on abuse and neglect required immediate investigation and protective measures, but the self-reported incident (SRI) was not filed until several days after the event. The investigation was still ongoing at the time of the report, and the facility had implemented increased supervision for Resident #51. The delay in reporting and the initial failure to protect Resident #12 from potential harm were key factors in the identified deficiency.
Failure to Update Care Plan for Resident with Behavioral Concerns
Penalty
Summary
The facility failed to ensure that a comprehensive person-centered care plan was updated with current interventions for a resident with behavioral concerns. The resident, who was cognitively intact and mostly independent in activities of daily living, was involved in an incident where he was found in a female resident's room, leading to allegations of inappropriate behavior. Following this incident, the resident was placed on 15-minute checks and subsequently on one-on-one supervision to prevent further occurrences. However, the care plan did not reflect these interventions, indicating a lack of documentation and communication among the care team. Interviews with staff, including a State Tested Nursing Assistant (STNA) and a Licensed Practical Nurse (LPN), confirmed the implementation of increased supervision measures. The Director of Nursing (DON) and the Administrator were aware of the situation and had initiated an investigation into the allegations. Despite these actions, the comprehensive care plan was not updated to include the one-on-one supervision, which is a requirement according to the Resident Assessment Instrument (RAI) 3.0 manual. This oversight was identified during a complaint investigation, highlighting a deficiency in the facility's compliance with care planning regulations.
Delayed Refund of Resident Fund Account
Penalty
Summary
The facility failed to ensure the timely return of funds from a resident fund account (RFA) following the discharge of a resident. This deficiency affected one resident, who had been admitted with medical diagnoses including schizophrenia, chronic obstructive pulmonary disease, asthma, hypertension, and anemia. The resident was discharged from the facility, but the remaining balance in their RFA was not refunded until several months later. The Business Office Manager confirmed that the resident had transferred to another facility and that there was no existing policy for handling RFAs at the time of the incident.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to ensure that staff followed infection control procedures during medication administration, specifically affecting one resident. The incident involved a registered nurse who prepared and administered medications to a resident without performing hand hygiene before or after the process. The nurse placed the medications directly into his bare hands before transferring them to a medication cup, which is against the facility's infection control procedures. The resident involved had a medical history that included Parkinson's disease, arthritis, hypertension, anxiety, heart failure, and depression. The resident required various levels of assistance with daily activities and had several physician orders for medications, including Carbidopa-Levodopa, glucosamine, Primidone, Buspar, hydroxyzine, and Coreg. The facility's policy on medication administration mandates adherence to infection control procedures, which were not followed in this instance, leading to the deficiency noted during the complaint investigation.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Eaton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Greenbriar Nursing Center | 1.5 mi | ★★★★★ | 3 | 0 |
| Vancrest Health Care Center Of Eaton | 1.7 mi | ★★★★★ | 12 | 0 |
| Arbor Trace Health & Living Community | 12.7 mi | ★★★★★ | 1 | 0 |
| New Lebanon Rehabilitation And Healthcare Center | 12.8 mi | ★★★★★ | 16 | 0 |
| Brookhaven Nursing & Rehabilitation Center | 13.2 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.