Health inspection·May 22, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement the interventions of the comprehensive care plan related to pacemaker care for Resident #92. This affected one resident (#92) of nineteen residents reviewed for comprehensive care plans. The facility census was 90. Findings include: Review of the medical record for Resident #92 revealed an admission date of 04/30/24. Diagnoses included cardiac pacemaker, syncope collapse, and atrioventricular block. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #92 had intact cognition and required supervision with activities of daily living. Review of Resident #92's care plan revealed a plan for decreased cardiac output related to pacemaker placement. Interventions included assessing for signs and symptoms of pacemaker failure that include dizziness, fainting, heart palpations, prolonged hiccups, and chest pain. Monitor and document signs of shortness of breath. Check oxygen saturation. Monitor for signs of elevated blood pressure including headache, dizziness, nosebleed, and visual changes. Review of the hospital discharge orders dated 04/30/24 revealed Resident #92 had a new pacemaker inserted on 04/24/24. There was a follow-up appointment scheduled for 05/24/24 for the pacemaker device. Review of the physician orders for May 2023 revealed no monitoring orders for a new pacemaker. Review of the skilled nursing assessments from 04/30/24 through 05/21/24 revealed there were no skilled nursing assessments on 05/09/24, 05/11/24, 05/12/24, 05/13/24, 05/14/24, 05/15/24, 05/16/24, and 05/20/24. Review of the vital signs tab in the electronic medical record (eMAR) from 04/30/24 through 4/21/22 revealed blood pressure, oxygen saturation, and temperatures were not documented on 05/09/24, 05/11/24, 05/12/24, 05/13/24, 05/14/24, 05/15/24, 05/16/24, and 05/20/24. Interview with Licensed Practical Nurse (LPN) #524, the unit manager, on 05/22/24 at 2:00 P.M. stated the skilled nursing assessment was where nurses would assess and document signs and symptoms of pacemaker failure. Further interview on 05/22/24 at 2:22 P.M. verified skilled nursing assessments and vital signs were not completed on 05/09/24, 05/11/24, 05/12/24, 05/13/24, 05/14/24, 05/15/24, (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 5 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 05/22/2024 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)