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 (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 2 Event ID: 365014 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 365014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brethren Retirement Community 750 Chestnut Street Greenville, OH 45331 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)