Mapleview Country Villa

Inspectors wroteBased on record review, interview and review of facility policy, the facility failed to ensure medications were obtained timely from the pharmacy and were administered according to physician orders. This affected one (Resident #81) of three residents reviewed for medication administration. The facility census was 90.

Inspectors wroteBased on observation, staff interview, review of facility menu, and review of diet spreadsheets, the facility failed to ensure residents who were ordered a puree diet received all food items on the menu. This affected five residents (#2, #24, #50, #68 and #70) who were identified as ordered a pureed diet. The facility census was 85.

Inspectors wroteBased on observation, staff interview, medical record review, and review of facility policy, the facility failed to maintain the call light in reach of Resident #7. This affected one resident (#7) and had the potential to affect all 85 residents residing in the facility.

Inspectors wroteBased on record review and staff interview the facility failed to notify the appropriate state agency (The Ohio Department of Mental Health) of a significant change in a resident's mental health condition as required. This affected one resident (Resident #1) of one resident reviewed for preadmission screening and resident review (PASRR). The facility census was 85.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure residents received adequate nail care. This affected one resident (#8) of three residents investigated for activities of daily living (ADL) care. The facility census was 85.

Inspectors wroteBased on medical record review, review of the incident log, review of Quality Assurance and Performance Improvement (QAPI) data, review of hospital records, review of facility policy, and interviews with staff, the facility failed to prevent a significant medication error for Resident #51 when the resident's insulin medication with insulin hold parameters, was not administered with meals as ordered beginning on 02/02/25 and then on 05/08/25 was administered outside of the set parameters. Actual Harm occurred on 05/08/25 when Resident #51, who had severe cognitive impairment and required diabetes management with insulin, was admitted to the hospital with hypoglycemia (when blood glucose dropped below the normal range of relatively 80 to 130 milligrams per deciliter [mg/dL]). [...]

Inspectors wroteBased on observation, interviews, record review, review of the PBJ (Payroll-Based Journal) Staffing Data Report, and review of facility assessment, schedules, incidents logs, resident care lists, policies and the staffing tool, the facility failed to provide adequate staffing to meet resident needs in the Rosewood residential area which contained three units, 200-hall front (a secured memory care unit), 200-hall middle, and 200-hall back. This affected 47 residents (#2, #3, #4, #5, #7, #8, #9, #10, #12, #14, #19, #20, #22, #24, #25, #27, #28, #30, #35, #36, #38, #40, #42, #45, #47, #49, #50, #51, #52, #55, #57, #58, #59, #60, #61, #62, #67, #68, #70, #71, #72, #75, #76, #79, #83, #84 and #85) who resided in the Rosewood residential area. The facility census was 88.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to treat Resident #51 with dignity and respect. This affected one (Resident #51) of three residents reviewed for resident rights and had the potential to affect all 88 residents who resided in the facility.

Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to maintain call lights within reach of Residents #24 and #50. This affected two (Residents #24 and #50) of 88 residents reviewed for call light accessibility. The facility census was 88.

Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility did not ensure Resident #52 was assisted with eating and drinking. This affected one (Resident #52) out of two residents reviewed that required feeding assistance. This had the potential to affect four (Residents #4, #36, #52, and #67) identified by the facility requiring assistance with feeding on the secured unit.

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility did not ensure residents had proper signage upon entry to their room indicating oxygen was in use and/or there was a physician order for the use of oxygen. This affected two (Residents #24 and #33) out of three residents reviewed for oxygen use. This had the potential to affect 14 (Residents #3, #7, #14, #24, #27, #28, #33, #35, #41, #44, #49, #51, #65, and #71) identified by the facility on oxygen.

Inspectors wroteBased on record review, interview, review of a self-reported incident (SRI), observation, and review of the facility policy, the facility did not ensure Resident #36 received trauma-informed care in accordance with professional standards of practice. This affected one (Resident #36) out of one resident reviewed for trauma informed care. This had the potential to affect four (Residents #36, #64, #84, and #87) identified by the facility with post-traumatic stress disorder (PTSD) and/or trauma.

Inspectors wroteBased on review of medical record, observation, interview, review of Center for Disease Control and Prevention (CDC) guidelines and review of facility policy, the facility did not ensure proper signage was utilized to identify Resident #78 was on transmission-based precautions (TBP) and did not ensure medical equipment was cleaned properly between resident use. This affected one (Resident #78) out of one resident identified by the facility on TBP and two (Residents #31 and #80) of three residents observed for proper infection control during the use of medical equipment. The facility census was 88.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to properly store medications by leaving eye drops, nasal spray, and pain relief gel at the bedside for later administration when Resident #16 did not participate in or have an order for self-medication administration. This affected one resident (#16) of three residents reviewed for medication administration. The facility census was 81.

Inspectors wroteBased on observation, staff interview, and facility policy review the facility failed to ensure the kitchen was clean and sanitary and food items were not expired. In addition, the hot water dish machine thermometer did not reach the appropriate rinse temperature, and the sanitizing sink was not at correct level to effectively kill virus or bacteria. This had the potential to affect all residents receiving food from the kitchen. The facility identified no residents were deemed no food by mouth. The facility census was 90.

Inspectors wroteBased 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.

Inspectors wroteBased on record review and interview, the facility failed to thoroughly complete a discharge recapitulation of stay for Resident #96. This affected one resident (#96) of three residents reviewed for discharge. The facility census was 90.

Inspectors wroteBased 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.

Inspectors wroteBased on observation and interview the facility failed to ensure staff wore hair nets prior to entering the kitchen. This had the potential to affect all residents except one resident (#92) who received nothing by mouth. The facility census was 93.

Inspectors wroteBased 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.