Inspection·May 14, 2025

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, photographs of meals & tray ticket review, and interview, the facility failed to follow Resident #90's meal preferences. This affected one resident (Resident #90) of four residents reviewed for preferences. The census was 68. Findings include: Review of the closed medical record for Resident #90 revealed an admission date of 04/18/25 and a discharge date of 05/09/25. Resident #90's diagnoses included diabetes, end stage renal disease and major depression disorder. Review of the 5-day admission Minimum Data Set (MDS) dated [DATE] revealed Resident #90 was cognitively intact. She required set up assistance with meals. Review of the Nutrition Data Collection/Evaluation dated 04/23/25 revealed Resident #90 had carrots listed as one of her dislikes. Review of the undated Meal Tracker printout, revealed carrots were listed as a dislike among several other dislikes for Resident #90. The printout stated her diet was updated on 04/23/25. Review of photographs provided by Resident #90's family revealed four photographs of meals with tray tickets with the plated meal. On 04/28/25 the lunch ticket listed brussel sprouts selected as the vegetable to be served and the photograph showed carrots were served. On 4/28/25 the dinner ticket listed whole kernel corn to be served as the vegetable and the photograph showed carrots were served. On 04/30/25 the lunch ticket listed brussel sprouts as the selected vegetable and the photograph revealed the selection was not served. On 05/02/25 the lunch ticket listed broccoli florets selected as the vegetable and the photograph showed carrots were served. Interview on 05/13/25 at 7:30 P.M. with Resident #90's family member revealed Resident #90 was not provided meals according to her preference and the photos supported this. Interview on 05/14/25 at 12:00 P.M. with the District Director of Dietary and at 3:15 P.M. with the Director of Nursing revealed they reviewed the photographs of meals with tray tickets and verified Resident #90 received food items listed on her dislike list for three of the meals. Review of the facility policy titled Dining and Food Preferences, revised 10/2022 revealed individual dining, food, and beverage preferences are identified for all residents. The individual tray (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: 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 05/14/2025 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)