Health inspection·May 18, 2023

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, record review, interview, and facility policy review the facility failed to prepare and store food items to prevent contamination and potential food borne illness. This had the potential to affect all 94 residents residing in the facility who consumed food prepared in the facility kitchen, including those with puree diets: Residents # 57, #50, #59, #70, #41, #1, and #51. There were no residents at the facility unable to consume food by mouth. Findings include: An observation on 05/16/23 at 4:03 P. M. in the kitchen revealed [NAME] #685 was beginning the puree process using a spatula placed directly on an unclean counter surface. There were obvious crumbs, dried liquid spots, and debris on the surface where she set the spatula to scrape the sides of the (Robot coupe) food processor blending breaded chicken strips. [NAME] #685 picked up the spatula from the unclean counter surface and stirred and scraped the side of the food processor. [NAME] #685 then placed the spatula down again directly on the unclean surface with a paste of pureed breaded chicken strips on it. [NAME] #685 ran the food processor again and picked up the spatula and used it second time to stir and scrape the breaded chicken fingers then put the spatula down on the unclean surface again. An interview on 05/16/23 at 4:10 P.M. with [NAME] #685 revealed she forgot to put the spatula on a clean surface and would throw out all the puree breaded chicken fingers. An interview on 05/16/23 at 4:11 P.M. with Dietary Manager #645 revealed the staff should never put the spatula down on an unclean surface and then reuse it to stir/scrape food in food processor. DM #645 then put a sheet of waxed paper down on the surface and two clean spatulas. The pureed breaded chicken fingers were thrown out and a new puree was started. An observation on 05/16/21 at 4:15 P.M. in the facility kitchen, Dietary Manager #645 was observed making peanut butter and jelly sandwiches on white bread. DM #645 then went from making sandwiches to pushing down the trash in an open garbage can with her bare hands. After pushing down the garbage with her bare hands without washing her hands or using hand sanitizer, she went back to finishing making the peanut butter and jelly sandwiches and then stored them for later, grabbing and cleaning off the peanut butter and jelly jars with and a kitchen towel and placing them back in storage. An interview on 05/16/23 with the Dietary Manager #645 at 4:17 P.M. revealed she should not have pushed the trash down with her bare hand and then failed to wash her hands before returning to the food preparation and storage. DM #645 stated she usually washes her hands all the time. (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: 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 05/18/2023 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)