Health inspection·November 7, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review and facility policy review, the facility failed to properly complete medication administration by leaving uncapped eye drops and nasal spray with pain relief gel at Resident #16's bedside and failed to administer medications to Resident #16 as ordered by the physician by error of omission or being late. This affected one resident (#16) of three residents reviewed for medication administration. The facility census was 81. Residents Affected - Few Findings include: Review of the medical record for Resident #16 revealed an admission date of 03/01/16. Diagnoses included spinal stenosis, restless legs syndrome, generalized anxiety disorder, gastro-esophageal reflux disease (GERD), radiculopathy, and chronic pain. The quarterly Minimum Data Set (MDS) assessment completed 09/25/24 indicated no cognitive impairment. Observation on 11/06/24 at 9:09 A.M. of Resident #16 in bed with a bedside table positioned across the bed within the resident's reach. On the table was a tube of Voltaren pain relief gel, a vial of uncapped artificial tears eye drops, and a vial of uncapped nasal saline spray. The bedside table was visibly soiled with food debris. Interview at the time of the observation with Resident #16 complained that the nurse left the medications there because he was eating breakfast and would return later to administer them. Resident #16 denied self-administering medications, and further complained there were times when his noon medication was given late, or some medications were not given at all. The nurse was not visible on the unit. Review of Resident #16's physician orders from October to November 2024 revealed artificial tears ophthalmic solution one percent, one drop in both eyes twice daily for dry eyes; sodium chloride nasal spray 0.65 percent, two sprays in both nostrils daily for dryness; and Voltaren external gel one percent to neck and shoulders topically three times daily for pain. There was no evidence of an order for self-administration of medications or to keep medications at bedside. Observation on 11/06/24 at 9:27 A.M. revealed Resident #16 had not changed position, and the uncapped eye drops and nasal spray with the tube of pain relief gel were still on the soiled bedside table within Resident #16's reach. Interview at the time of the observation with Resident #16 confirmed the nurse had not yet administered the medications. The nurse had returned but the resident told the nurse to forget it and give them around 11:30 A.M., but the nurse still left the medications on the bedside table. The nurse was not visible on the unit but was located on a nearby secured memory care unit administering medications. Interview on 11/06/24 at 9:30 A.M. with Licensed Practical Nurse (LPN) #245 confirmed Resident #16's eye drops and nasal spray were left uncapped on the bedside table with the pain relief gel, (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 11/07/2024 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)