Health inspection·April 16, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure staff provided a resident assistance with feeding. This affected one (#56) of the three residents reviewed for assistance with meals. The facility census was 74. Residents Affected - Few Findings include: Review of the medical record for Resident #56 revealed an admission date of 11/16/23 with medical diagnoses of metabolic encephalopathy, chronic obstructive pulmonary disease, Alzheimer's disease, gastroenteritis, and anxiety. Review of a quarterly Minimum Data Set (MDS) assessment, dated 03/19/24, indicated Resident #56 had severe cognitive impairment and was dependent for eating, toilet hygiene, bathing, bed mobility, and transfers. Review of a physician order dated 11/22/23 revealed Resident #56 was to have one-to-one feeding assistance. Review of a physician order dated 12/18/23 revealed Resident #56 was to have a regular diet with pureed texture and regular liquids. Review of a physician order dated 02/09/24 revealed Resident #56 was ordered a divided plate with meals, and an order dated 03/05/24 for a sippy cup to be used for drinking related to hand dexterity. Review of Resident #56's activities of daily living (ADLs) care plan revealed Resident #56 was dependent for all ADLs. Further review of the resident's medical record revealed a nutritional care plan with interventions for weight loss management to included one-on-one feed assistant for meals. Review of the medical record for Resident #56 revealed the resident weighed 164.2 pounds on 03/11/24, weighed 158.2 pounds on 04/10/24, and weighed 161.0 pounds on 04/15/24. Review of a nutrition note dated 04/11/24 at 2:15 P.M. reveled Resident #56 triggered for a significant weight loss on 04/10/24 (158.2 pounds) from 03/17/24 (167.8 pounds), a 9.4 pound weight loss (5.6 percent) in 25 days. Review of the medical record revealed a nursing progress note dated 04/14/24 at 1:05 P.M. which indicated Resident #56 required total care for ADLs and was a one person assist with feed/meals. Observation on 04/15/24 at 12:18 P.M. to 12:40 P.M. revealed Resident #56 was sitting in the dining room with a small bowl of applesauce in hand and divided plate of food sitting on table. The observation revealed there were no nursing staff present in the dining room to assist Resident #56 with the meal. Further observation revealed Dietary Aide #103 served other residents their lunch trays (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: 365497 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 365497 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at the Greene 4381 Tonawanda Trail Dayton, OH 45430 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)