Health inspection·June 30, 2023

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, review of the facility's Self-Reported Incidents (SRIs), and policy review, the facility failed to ensure a resident was provided a diet as ordered, in a form to meet the resident's needs. This affected one (Resident #125) resident of the three residents reviewed for mechanically altered diets. The facility identified 22 residents who received a mechanically altered diet. The facility census was 62. Findings include: Review of the medical record for the Resident #125 revealed an admission date of 06/21/22 with medical diagnoses of history of cerebral infarction, dysphagia, aphasia, atrial fibrillation, and hypertension. Resident #125 enrolled onto hospice services on 05/23/23 and expired 05/24/23. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #125 had severe cognitive impairment, required extensive staff assistance with bathing, toileting, and transfers and required supervision with set-up assistance for eating. Resident #125 received a mechanically altered diet. Review of the care plan dated 01/11/23 revealed Resident #125 was at risk for aspiration due to dysphagia. The interventions included to provide pureed solids and nectar liquids. Review of Resident #125 physician's orders revealed an order dated 05/12/23 for regular diet, pureed texture, with nectar/mildly thick consistency. Review of the Self-Reported Incident (SRI) dated 06/06/23, revealed the facility investigated an anonymous complaint which stated State Tested Nursing Assistant (STNA) #800 fed Resident #125 part of a donut STNA #800 was eating, even though Resident #125 was on a pureed diet. The SRI indicated the incident occurred on 05/20/23 or 05/21/23 during State Tested Nursing Assistant (STNA) training. Further review of the SRI revealed multiple witness statements confirmed STNA #800 fed Resident #125 part of a donut. Further review of the facility's investigation revealed no evidence the facility completed on-going monitoring to ensure staff fed residents ordered diets in correct form. Interview on 06/30/23 at 12:32 P.M. via phone with STNA #232, confirmed she witnessed STNA #800 feed Resident #125 part of STNA #800's donut. STNA #232 stated Resident #125 was observed having difficulty swallowing the donut but did not choke on the donut. Interview on 06/30/23 at 12:25 P.M. with Assistant Executive Director (AED) #292 confirmed the Page 1 of 2 365014 365014 06/30/2023 Brethren Retirement Community 750 Chestnut Street Greenville, OH 45331

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility received an anonymous letter on 06/06/23, which detailed concerns related to STNA #800 feeding Resident #125 non-pureed food on 05/20/23 or 05/21/23. AED #292 stated the facility immediately initiated an investigation into the allegation and obtained multiple witness statements. AED #292 stated based on witness statements, the facility was able to substantiate the allegation that STNA #800 fed Resident #125 food that was not in a form that met the resident's needs. AED #292 confirmed the letter was received after Resident #125 had expired. AED #292 verified no on-going monitoring was completed to ensure staff were providing residents with diets as ordered. Review of facility policy titled, Resident Therapeutic Diet, dated 04/02/19, revealed a pureed diet is a regular diet that is mechanically altered for residents who have difficulty chewing or swallowing. All food is to be pureed to a mashed potato consistency. This deficiency represents non-compliance investigated under Complaint Number OH00143691. 365014 Page 2 of 2