Maple Gardens Rehabilitiation And Nursing Center
515 South Maple Street, Eaton, OH 45320 · For profit - Limited Liability company · 85 certified beds · (937) 456-5537 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0569)
- a high number of inspection citations overall (18) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 4.4% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 9.5% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.2% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.4% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 30.4% | 30.1% | 6.5% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.0% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 5.2% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 20.7% | 25.5% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 98.2% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.9% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 23.4% | 21.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 4.5% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 5.4% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 84.9% | 75.6% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 22.4% | 24.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 4.7% | 12.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.67 | 1.73 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.51 | 1.80 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
49.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 26 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.18 therapist hours per resident per day in 2026Q1 — more than 18% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 49.8%CMS range 33.9–65.6 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.7%CMS range 6.3–15.1 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.9%CMS range 3.3–9.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.16 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 85 beds and averages 67.6 residents a day — about 80% occupied, or roughly 17 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.25 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.39 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.04 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.91 hrs/resident/day on weekends vs 3.39 on weekdays — 14% thinner on weekends. RN hours go from 0.47 to 0.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
18 citations, most serious first. The 10 most serious are shown; the remaining 8 are one tap away and print in full.
- Potential for harm · D2026-06-24 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Interventions include education on successful coping and interaction strategies. Resident #3 had a care plan which documented the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-10 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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.Findings include:Review of the closed medical record for Resident #64 revealed an admission date of 11/07/25 and a discharge date of 05/27/26. Diagnoses included acute pyelonephritis, Type Two Diabetes Mellitus with diabetic neuropathy, primary lateral sclerosis, hypertension, functional quadriplegia, chronic hepatitis, factitious disorder imposed on self, major depressive disorder, myoneural disorder, generalized anxiety disorder, bipolar disorder, personality disorder, other chronic pain, chronic kidney disease stage three, and chronic respiratory failure with hypoxia.Review of the significant change Minimum Data Set (MDS) assessment, dated 02/27/26, revealed this resident was cognitively intact. This resident was assessed to require setup assistance for eating, supervision for oral hygiene, and was dependent for toileting, bathing, dressing, personal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-02-27 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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.Findings included:1. Review of the medical record revealed the facility admitted Resident #60 on 03/07/25. Diagnoses included type two diabetes mellitus. Review of Resident #60's Care Plan Report, included a focus area initiated 03/11/25, that indicated the resident had diabetes mellitus. Interventions directed staff to monitor blood sugar levels. During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-27 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. Medications in the medication cart included lisinopril (used to treat high blood pressure), Amlodipine (used to treat high blood pressure and coronary artery disease), and glipizide (used to treat type two diabetes).During an interview on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-27 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. Findings included:Review of the medical record revealed the facility admitted Resident #44 on 01/19/26. Diagnoses included hyperlipidemia, gastro-esophageal reflux disease (GERD), adult failure to thrive (FTT), atherosclerotic heart disease (AHD), ascites, and depression. Review of a Diagnosis Report indicated Resident #44 also had diagnoses that included protein calorie malnutrition (PCM), cirrhosis of the liver, type 2 diabetes mellitus (DM2), and hyperlipidemia. Review of Resident #44's Care Plan Report included a problem statement that indicated the resident had nutritional problems related to severe PCM, cirrhosis of the liver, DM2, hyperlipidemia, GERD, adult FTT, and AHD. Interventions directed staff to provide and serve diet as ordered and monitor/record intake for each meal. Review of an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-01-16 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct 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.
What the surveyor found here — an excerpt from the official record, may be distressing
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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-13 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. Review of the medical record for the Resident #12 revealed an admission date of 06/30/21 with medical diagnoses of multiple sclerosis (MS), chronic obstructive pulmonary disease (COPD), dementia, Depression, and peripheral vascular disease (PVD). The medical record revealed a discharge of date 11/11/24. Review of the medical record for Resident #12 revealed a quarterly Minimum Data Set (MDS) assessment, dated 08/21/24, which indicated Resident #12 had moderate cognitive impairment and was dependent for all activities of daily (ADL's) except required set-up with eating. The MDS revealed Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-13 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. Review of the medical record for the Resident #12 revealed an admission date of 06/30/21 with medical diagnoses of multiple sclerosis (MS), chronic obstructive pulmonary disease (COPD), dementia, Depression, and peripheral vascular disease (PVD). The medical record revealed a discharge of date 11/11/24. Review of the medical record for Resident #12 revealed a quarterly Minimum Data Set (MDS) assessment, dated 08/21/24, which indicated Resident #12 had moderate cognitive impairment and was dependent for all activities of daily (ADL's) except required set-up with eating. The MDS revealed Resident #12 was non-ambulatory. Review of the medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-13 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. Review of the medical record for the Resident #12 revealed an admission date of 06/30/21 with medical diagnoses of multiple sclerosis (MS), chronic obstructive pulmonary disease (COPD), dementia, Depression, and peripheral vascular disease (PVD). The medical record revealed a discharge of date 11/11/24. Review of the medical record for Resident #12 revealed a quarterly Minimum Data Set (MDS) assessment, dated 08/21/24, which indicated Resident #12 had moderate cognitive impairment and was dependent for all activities of daily (ADL's) except required set-up with eating. The MDS revealed Resident #12 was non-ambulatory. Review of the medical record for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-13 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Review of the medical record for Resident #51 revealed an admission date of 01/20/17 with medical diagnoses of chronic obstructive pulmonary disease (COPD), anxiety, congestive heart failure, schizoaffective disorder, and chronic ischemic heart disease. Review of the medical record for Resident #51 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #51 was cognitively intact and was independent with all ADL's except required supervision with bathing. Review of the medical record for Resident #51 revealed no documentation to support a comprehensive person-centered care plan was developed for behavioral concerns with the interventions of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 8 citations
- Potential for harm · D2024-11-05 · tag F0569 — isolatedNotify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
What the surveyor found here — an excerpt from the official record, may be distressing
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. 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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-05 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
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. 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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-03-30 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. Findings include: During the initial tour of the kitchen on 03/06/23 at 8:05 A.M., Dietary Aide (DA) #71 was observed with facial hair while serving breakfast. Further observation revealed DA #71 was not wearing a beard protector nor gloves while serving breakfast meals on the tray line. Additionally, DA #75 was observed placing bread in a toaster without gloves in place. During continued observations, revealed DA #75 touched her arms and continued to place bread in the toaster without washing her hands. Interview on 03/06/23 at 8:15 A.M., revealed Dietary Supervisor (DS) #76 verified findings and reported staff are to always cover beard and hands while serving meals on the tray line. DS #76 verified DA #75 touched her arms and failed to wash her hands before loading more bread in the toaster. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-30 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Review of the medical record for Resident #215 revealed an admission date of 02/01/23. Diagnoses included, but not limited to, PTSD, Parkinson's Disease, chronic obstructive pulmonary disease (COPD), vascular dementia, history of Coronavirus (COVID-19), and hypertension. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] for Resident #215, revealed the resident had an intact cognition. The resident had a Brief Interview for Mental Status (BIMS) assessment score of 15 which indicated intact cognition. Assessment indicated the resident had no hallucinations, delusions, behaviors or concerns with his mood and /or rejection of care. Review of the progress…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2019-12-12 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. Findings included: Observation of Resident #11's bathroom on 12/09/19 at 10:17 A.M. revealed the floor was badly stained and around the bottom of the toilet there was a dark thick substance and the floor was sticky. Observation on 12/09/19 at 11:25 A.M. of Resident #19's bathroom revealed the tile was discolored. Observation of Resident #45's bathroom floor on 12/09/19 at 12:06 P.M. revealed it was badly stained under the sink and around and behind the toilet. Observation on 12/09/19 at 2:27 P.M. of Resident #37's and #14's shared bathroom revealed under the sink there were dark stains. Observation with the Administrator and Housekeeping Supervisor (HS) #41 on 12/12/19 at 1:55 P.M. verified the conditions of the above mentioned bathrooms for Resident #11, #19, #45, #37 and #14. Interview with the Administrator on 12/12/19 at 2:00 P.M.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-12-12 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. Review of Resident #14's medical record, revealed he was admitted to the facility on [DATE] with pertinent diagnoses including malignant cancer of the spinal meninges, congestive heart failure, diabetes, anxiety disorder, morbid obesity, liver disease, major depressive disorder, insomnia, sleep apnea, and dementia with behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident was cognitively impaired with no behaviors. On 09/19/19, a care plan was developed that documented the resident was on psychotropic medications including antidepressant and anti-anxiety medications. Interventions included administering medication as ordered, monitoring for signs and symptoms of adverse…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-12-12 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Review of Resident #39's record, revealed she was admitted to the facility on [DATE], with diagnoses including neurogenic arthritis, type 2 diabetes, hypertension, nephrotic syndrome, edema, severe protein caloric malnutrition, visual loss, chronic kidney disease with dialysis, and peripheral vascular disease. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed the resident participated in a Brief Interview for Mental Status (BIMS) with a score of 15, fully intact cognitive abilities. The MDS revealed the resident had severe vision impairment and required extensive assistance of staff with bed mobility, transferring, dressing, and toilet use tasks. She was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-12-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. Review of Resident #39's record, revealed she was admitted to the facility on [DATE], with diagnoses including neurogenic arthritis, type 2 diabetes, hypertension, nephrotic syndrome, edema, severe protein caloric malnutrition, visual loss, chronic kidney disease with dialysis, and peripheral vascular disease. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed the resident participated in a Brief Interview for Mental Status (BIMS) with a score of 15, fully intact cognitive abilities. The MDS revealed the resident had severe vision impairment and required extensive assistance of staff with bed mobility, transferring, dressing, and toilet use…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to GARDEN HEALTHCARE GROUP — 6 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.5 | +1.5 vs chain |
| Health inspection | 4 of 5 | 2.0 | +2.0 vs chain |
| Staffing | 1 of 5 | 1.2 | -0.2 vs chain |
| Quality measures | 5 of 5 | 4.8 | +0.2 vs chain |
The other 5 homes this chain runs (chain average 2.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CHICKIESTRONG EATON GARDENS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 80% | since 12/30/2016 |
| GAMZEH, DAVID | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | 5% | since 12/30/2016 |
| GLATZER, AKIVA | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 5% | since 12/30/2016 |
| FRASHER, TODD | Individual | W-2 MANAGING EMPLOYEE | — | since 12/30/2016 |
| LAHASKY, EPHRAM | Individual | CORPORATE OFFICER | — | since 12/30/2016 |
| LESHKOWITZ, ELI | Individual | CORPORATE OFFICER | — | since 12/30/2016 |
| GARDEN HEALTHCARE GROUP LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/30/2016 |
CMS files one row per role, so the 8 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $569K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365557. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-27, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.