Health inspection·November 28, 2023

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, record review, and interview the facility failed to ensure proper serving sizes were served according to the menu spreadsheet for the corn, creamed corn, pureed corn, and the pureed Spanish rice served at lunch. This had the potential to affect all residents one resident (#92) who received nothing by mouth. The facility census was 93. Findings include: Observation on 11/28/23 at 12:05 P.M. of tray line service revealed [NAME] #508 serving corn using a three-ounce white handled serving spoon, a red handled serving spoon for the creamed corn, a blue handled scoop to serve the pureed Spanish rice, and a blue handled scoop to serve the pureed corn. Review of the lunch menu and spread sheet dated 11/28/23 revealed the serving utensil for the corn was a #8 scoop equaling four-ounce. The serving for the creamed corn was a #8 scoop equaling four-ounce serving. The serving for the pureed Spanish rice and pureed corn was a #8 scoop equaling four-ounce. Interview on 11/28/23 at 12:30 P.M. with Dietary Manager (DM) #513 verified the observation and stated the red handled serving spoon for the creamed corn provided two-ounce servings. DM #513 stated the blue handled scoop used to serve the pureed corn and pureed Spanish rice was a #16 scoop providing two ounces. DM #513 stated they had the color-coded chart on the wall to identify what the servings each handled colored scoop served. Review of the color-coded chart used to identify the scoop serving sizes indicated the blue handled #16 scoop provided two-ounce servings and the grey handled #8 scoop provided four-ounce servings. This chart did not indicate serving sizes for the spoons. This deficiency was an incidental finding discovered during the course of the complaint investigation. 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 11/28/2023 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)