Inspection·January 24, 2019

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some extensive to dependent assistance and staff participation for eating. The resident could not be interviewed due to cognition. Observation of the lunch meal on 01/22/19 starting at 12:30 P.M. revealed Resident #33 was served her plate consisting of mechanically altered pork, rice and cauliflower at 12:35 P.M. Her plate remained uncovered to air and untouched until staff came by to assist her at 12:55 P.M. Per surveyor intervention, temperature readings of the food on Resident #33's plate were obtained by Food Service Director (FSD) #202 at 12:58 P.M. and were as follows: pork 111 degrees Fahrenheit (F); cauliflower 96 degrees F and rice 115 degrees F. Interview with FSD #202 at the time of the above observation revealed foods should be at least 135 degrees F at the time of presentation to the table and verified food should not have been sitting out uncovered before Resident #33 was assisted at the meal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365893 If continuation sheet Page 2 of 4 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 365893 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berea Center 49 Sheldon Rd Berea, OH 44017 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)

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure consistent use of adaptive equipment for one resident (Resident #17) of 43 residents observed for dining (Resident #36 and Resident #38 were identified by the facility as receiving nothing by mouth). The facility census was 45 residents. Residents Affected - Few Findings include: Review of Resident #17's medical record revealed an admission date of 11/01/16 and diagnoses including dementia, right wrist contracture, bipolar disorder, falls and vitamin D deficiency. Review of an annual minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #17 was cognitively impaired, had a mechanically altered diet and had no weight loss or weight gain. Review of physician's orders in both the paper chart as well as the electronic medical record revealed Resident #17 was on a puree diet with honey thick liquids and required a small bolus spoon (adaptive device used for those with decreased oral motor strength to ensure food is entirely consumed). Review of a nutrition assessment dated [DATE] revealed Resident #17 received a pureed diet with honey thick liquids and required a small bolus spoon. Review of a nutrition care plan revealed Resident #17 was at risk for choking at meals and pocketed food (held it in his cheeks) and required feeding assistance at meals. Interventions included to assist with feeding Resident #17 including alternating small bites and sips, following any safe feeding strategies per speech-language pathologist guidelines and use of the small bolus spoon. Observation of the lunch meal on 01/23/19 starting at 12:45 P.M. revealed State Tested Nurse Aide (STNA) #200 feeding Resident #17 soup as well as thickened water with a plastic spoon. A bolus spoon was available and used for the pureed items on the resident's plate. STNA #200 continued to use the plastic spoon to provide water to Resident #17 at 12:53 P.M. Resident #17 coughed several times throughout the observation. Observation of the lunch meal on 01/24/19 starting at 12:26 P.M. revealed STNA #200 seated to the right of Resident #17. STNA #200 brought Resident #17's tray to the table at 12:34 P.M. which consisted of two small bolus spoons, a glass of thickened milk, a glass of thickened water, a plate with pureed entrees and sides, soup and pudding. STNA #200 then went over to the medication cart to grab several plastic spoons off the cart. STNA #200 was noted to use these plastic spoons to provide Resident #17 thickened water at 12:37 P.M., 12:44 P.M. and 12:51 P.M. and soup at 12:48 P.M. Resident #17 coughed several times throughout the observation. Interview on 01/24/19 at 12:58 P.M. with STNA #200 revealed she had fed Resident #17 on 01/23/19 and on 01/24/19. STNA #200 did not tell the surveyor why she used a plastic spoon to feed Resident #17 soup instead of the bolus spoon and stated she used the plastic spoon on the thickened water to ensure he had enough to drink. Interview on 01/24/19 at 1:03 P.M. with Occupational Therapist #201 verified Resident #17 was to have the bolus spoon for all items during the meal and showed the surveyor the physician's order in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365893 If continuation sheet Page 3 of 4 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 365893 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berea Center 49 Sheldon Rd Berea, OH 44017 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)

F 0810 the resident's chart stating this information. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365893 If continuation sheet Page 4 of 4