Inspection·April 20, 2021

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of facility policy the facility failed to ensure complete and accurate documentation in resident medication administration records for Residents #1, #57 and #60 and for application of elbow and hand splints for Resident #20. This affected four of nine residents reviewed for documentation. The facility census was 72. Findings include: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, high blood pressure (HTN), and unspecified dementia without behavioral disturbance. Physician orders included an order dated 12/30/20 for Humulin R Solution 100 UNIT/ML (Insulin Regular Human), inject as per sliding scale: if 0 - 70, follow Hypoglycemic Protocol; 71 - 150 No Coverage; 151 200 = 3 units (u); 201 - 250 = 5u; 251 - 300 = 8u; 301 - 350 = 10u; 351 - 400 = 13u; 401+ = 16u Notify MD/NP, to be given subcutaneously before meals and at bedtime. The Minimum Data Summary (MDS) 3.0 dated 03/26/21 revealed Resident #1 was cognitively intact with fluctuating periods of inattention, and required supervision and setup for Activities of Daily Living (ADL). Review of the Medication Administration Record (MAR) for Resident #1 from 01/01/21 to 04/19/21 revealed blood sugar levels of 404 on 02/02/21, 418 on 02/20/21 and 404 on 03/02/21. Review of the progress notes from 01/01/21 to 04/19/21 revealed no documentation that the medical doctor (MD) or nurse practitioner (NP) were notified. Interview on 04/19/21 with Licensed Practical Nurse (LPN) #200 at 12:30 P.M. revealed she would usually text the NP right after receiving a blood sugar if the order specified it, then document it in progress notes. Interview on 04/19/21 at 12:38 P.M. with Registered Nurse (RN) #302 verified the blood sugar readings above 400 for Resident #1 and contact with the NP should have been documented in progress notes but it was not done for 02/02/21, 02/20/21 and 03/02/21. 2. Resident #57 was admitted on [DATE] with diagnoses including chronic atrial fibrillation, Alzheimer's disease, hypertensive heart disease and vascular dementia. (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 3 Event ID: 366433 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 366433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mapleview Country Villa 775 South Street Chardon, OH 44024 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)