Health inspection·December 16, 2025

F 0805 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of facility Self-Reported Incidents (SRIs), staff interview, and policy review, the facility failed to provide a resident's food in the correct texture to meet individual needs per physician's orders for one (Resident #1) resident. This resulted in actual harm when Resident #1 choked on the food of incorrect texture which caused the need for cardiopulmonary Resuscitation (CPR) and hospitalization. This affected one (Resident #1) of three residents reviewed for specialized diets. The facility census was 50. Findings include: Record review revealed Resident #1 was originally admitted to the facility on [DATE] with diagnoses including type 1 diabetes, chronic obstructive pulmonary disease, dementia, personal history of transient ischemic attack, cerebral infarction, gastro-esophageal reflux disease, and anxiety disorder. Review of Resident #1's Minimum Data Set (MDS) significant change assessment, dated 12/09/25, revealed he was cognitively intact. He required supervision with eating and was dependent on activities of daily living (ADL). Review of the Care Plan for Resident #1 dated 12/09/25 revealed he was at risk for changes to nutrition due to risk of aspiration related to dysphagia. Interventions included providing his diet as ordered, monitoring for signs of aspiration and referral to speech therapy as needed. Review of the physician orders on 12/04/25 revealed Resident #1 was ordered a regular diet with minced and moist texture. Review of a nursing progress note for Resident #1 dated 12/04/25 revealed an unidentified Certified Nursing Assistant (CNA) #125 yelled from Resident #1's room that the resident was blue and not breathing. A nurse ran to assist, and no visible breathing was noted. The nurse instructed the staff to call for additional assistance and to call 911. Resident #1 was lowered to the floor and found to be choking on food. Some breath was noted while he was tongue thrusting to remove food. He was able to dislodge some food, and more was dislodged with a mouth sweep. Cardiopulmonary resuscitation (CPR) was initiated when no pulse was found and continued until emergency services personnel (EMS) arrived and took over. EMS reported Resident #1 had a pulse when they left the facility. Review of an additional progress note dated 12/04/25 revealed the nurse called the hospital for an update and was notified Resident #1 had been intubated and would be admitted . Review of the Self-Reported Incident (SRI) dated 12/05/25 revealed Resident #1 was found unresponsive in his room on 12/04/25 at approximately 6:00 P.M. CPR was immediately started and 911 was called. Food was noted in Resident #1's mouth during resuscitation measures. During the investigation it was noted Resident #1 generally ate in his room and had an order for a minced and moist diet which he was able to consume with intermittent supervision from staff. Social Worker (SW) #303, who normally would not prepare or serve meals provided a plate without checking Resident #1's diet order. She provided a regular texture meal. Approximately six minutes after receiving the wrong diet order, a CNA #125 walked into the room with a plate containing the correct diet and found Resident #1 unresponsive. CNA #125 immediately Page 1 of 3 366393 366393 12/16/2025 Otterbein at Maineville 201 Marge Schott Way Maineville, OH 45039

F 0805 Level of Harm - Actual harm Residents Affected - Few called for assistance with CPR initiated and 911 called. He was subsequently transferred to the hospital. The facility took corrective actions but did not substantiate neglect. Review of the hospital discharge paperwork for Resident #1 dated 12/09/25 revealed he was admitted from 12/04/25 through 12/09/25 with a diagnosis of cardiac arrest and pneumonitis to due inhalation of food and vomit. He was released with a diet order of a regular diet with pureed texture and moderately thick liquids. During an interview on 12/15/25 at 1:30 P.M., the Administrator and Director of Nursing (DON) confirmed all staff were trained on 11/20/25 verifying diet orders prior to serving meals in anticipation of the upcoming holiday dinner. On 12/04/25 the facility had a holiday dinner which included turkey and mashed potatoes. SW #303 heard staff state Resident #1 had not yet received a plate and she thought he would enjoy the garlic mashed potatoes, so she made him a plate and provided it without checking his diet order. About two minutes later she brought him a napkin and he was fine. About six minutes later an aide brought the correct diet to him not knowing he had been provided the wrong diet and found him unresponsive. She called for the nurse who began CPR and he was sent out to the hospital where he was on a ventilator in the intensive care unit (ICU) a couple of days and then returned to the facility with his diet downgraded to pureed. There were no other residents provided the wrong diet texture during this holiday meal on 12/04/25. During an interview on 12/15/25 at 3:38 P.M., Registered Nurse (RN) #168 stated revealed they were having a holiday dinner, and the social worker was assisting with ensuring all residents received a meal so she brought Resident #1 a plate of food without checking his diet order. A few minutes later CNA #125 brought Resident #1 a plate with the correct diet texture unaware he had already been provided a plate and found him unresponsive. CNA #125 immediately contacted RN #168 who assisted her with lowering Resident #1 to the floor. She assessed him found he was choking on food and assisted with clearing his airway. She was then not able to find a pulse and began CPR which she continued until EMS arrived. She stated EMS reported he had regained a pulse when they were leaving. During an interview on 12/15/25 at 4:02 P.M. CNA #125 stated as she was preparing a plate for Resident #1 with his correct diet, the social worker brought him a plate with a regular texture. She stated she was not aware he had been given the incorrect plate of food until she took him the food and found him unresponsive. She immediately called for the nurse and assisted with lowering him to the floor so the nurse could begin CPR while she called 911. Review of the policy titled Neighborhoods Diet, revised 12/02/21, revealed that a minced and moist diet consisted of a regular diet with textured altered for those with difficulty swallowing and/or chewing. Food can be eaten with fork or spoon, scooped or shaped onto the plate in a ball, soft and moist with no separate thin liquids, minimal chewing. Meat is finely minced or chopped. Fruit mashed or drained of excessive juice, vegetables finely minced or chopped or mashed, cereal very thick and smooth, and no regular dry bread. The deficient practice was corrected on 12/05/25 when the facility implemented the following corrective actions: - - On 12/04/25 Resident #1 was immediately assessed by RN #168 and CPR was initiated and he was sent to the hospital - - On 12/04/25 RN #151and Assistant Director of Nursing (ADON #168) conducted an audit and assessment of all residents either through interview or physical assessment with no concerns. - - -On 12/04/25 Education was sent by the Administrator to all staff via an email system and in-person training was completed by the Administrator, the Assistant Administrator (AA #181) and the DON with all staff regarding how to verify diet orders and the importance of following them. Staff not trained by 12/05/25 was not permitted to work until education was completed. - -On 12/04/25 All resident records were audited by the [NAME] President of Operations (VPoO #306) and the DON to identify anyone who currently required any type of modified diet to ensure it was correctly listed and to clarify the level of supervision needed with meals for each 366393 Page 2 of 3 366393 12/16/2025 Otterbein at Maineville 201 Marge Schott Way Maineville, OH 45039

F 0805 Level of Harm - Actual harm Residents Affected - Few resident. No one else in the same house identified. - -On 12/05/25 A root cause analysis was completed by VPoO #306, AA #181 and the DON regarding the incident and statements were obtained from all staff present. The root cause analysis revealed Social Worker (SW) #303 had not reviewed the diet orders before serving the food. Staff present were RN #168, LPN #142, SW #303, and CNA #104 and #125. - - -On 12/05/25 A Quality Assurance Performance Improvement (QAPI) meeting was held with the Medical Director to discuss the incident and action plan. Members in attendance were the Medical Director, Administrator, DON, RN #168, SW #303 and the Director of Rehab/SLP #290. - -On 12/05/25, SW #303 was terminated from the facility. - -On 12/06/25, two random audits were conducted by the DON daily to ensure the diet books had the correct diet orders and residents received the correct orders and level of supervision needed. The audits consisted of two residents each day for two weeks, two residents a week for two weeks and then two residents a month for two months. This deficiency represents non-compliance investigated under Master Complaint Number 2690997 and Complaint Number 2689516. 366393 Page 3 of 3