Inspection·April 30, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview, and medical record review the facility failed to ensure Resident #42 consistently recieved a divided plate with all meals as requested. The affected one (Resident #42) of three residents reviewed for resident preferences. The facility census was 63. Findings include: Review of the medical record for Resident #42 revealed an admission date of 03/03/20. Diagnoses included but were not limited to Alzheimer's dementia, dysphagia, and failure to thrive. Review of the 03/28/24 Minimum Data Set assessment for Resident #42 revealed Resident #42 had mild cognitive impairment. Review of Resident #42's diet ticket revealed a preference of a divided plate with meals. Review of Resident #42's current care plans including the nutritional care plan dated 04/12/24 revealed no information related to the use of a divided plated or Resident #42's request to have all meals served on a divided plate. Observation on 04/23/24 at 12:39 P.M. revealed Resident #42's lunch meal was not served on a divided plate. Resident #42 confirmed she was not provided a divided plate as requested. Observation on 04/24/24 at 12:40 P.M. revealed Resident #42's lunch meal was not served on a divided plate. Resident #42 confirmed she did had not been provided a divided plate as requested. Interview on 04/24/24 at 1:35 P.M. with District Manger (DM) #265 confirmed Resident #42's meal ticket had a preference of a divided plate. DM #265 said Resident #42 shared her preference for a divided plate and the information was placed on her diet ticket. DM #265 explained Resident #32 wanted a divided plate because she did not want different food types touching. Interview on 04/25/24 at 7:52 A.M. with Resident #42 revealed she was not always provided with a divided plate. Review of the 07/31/20 revised facility policy called Resident Food Preferences revealed the resident's clinical record would document the resident's like and dislikes and special dietary instructions . This deficiency represents non-compliance investigated under Complaint Number OH00152644. 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 4 Event ID: 365718 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 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)