Mapleview Country Villa

In the surveyor’s words

From the most serious findings on record at Mapleview Country Villa, in the surveyor’s own words.

• Actual harm, isolatedF760Jun 16, 2025

  Based 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]). […]

• No harm, potential for more than minimal, widespreadF812May 22, 2024

  Based 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. Finding include: 1. Observation during the initial kitchen tour on [DATE] between 9:00 A.M. and 11:00 A.M. with Dietary Manager #688 revealed the following concerns: The dairy walk-in cooler was observed to have six expired milk pints for resident use. […]

• No harm, potential for more than minimal, widespreadF803Nov 28, 2023

  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 Cook #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. […]

• No harm, potential for more than minimal, widespreadF812Nov 28, 2023

  Based 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. Findings include: Observation on 11/28/23 at 12:41 P.M. of Laundry Staff (LS) #234 with long hair in a ponytail enter the kitchen without a hairnet, carrying clean brown folded napkins. LS #234 stopped near the steam table and handed dietary staff the folded napkins and had them sign a piece of paper. Interview at this time with Assistant Administrator (AA) #504 verified the observation and stated she will ensure LS #234 was educated on putting on a hairnet prior to entering the kitchen. Interview on 11/28/23 at 12:42 P.M. […]

• No harm, potential for more than minimal, widespreadF812May 18, 2023

  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 Cook #685 was beginning the puree process using a spatula placed directly on an unclean counter surface. […]