Inspection·October 31, 2019

F 0641 Ensure each resident receives an accurate assessment. 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 the comprehensive assessment for Resident #3 was accurate for dental and Resident #20 for life expectancy. This effected two of 20 residents whose comprehensive assessments were reviewed. The facility census was 46. Residents Affected - Few Findings include: 1. Record review revealed Resident #3 was admitted on [DATE] with diagnoses which included gastroesophageal reflux disease, major depression, anxiety, cerebral palsy, constipation, and dysphagia. Interview with Resident #3 on 10/28/19 at 10:03 A.M. revealed she had dentures that had been relined but they rubbed in two spots and need to be tweaked. Observation of Resident #3 on 10/28/19 at 10:03 A.M., 10/29/10 at 3:20 P.M. and 10/30/19 at 8:28 A.M. revealed the resident was edentulous and was not wearing dentures. Review of the annual comprehensive assessment dated [DATE] revealed the question referring to the resident's oral/dental status indicated Broken or loosely fitting full or partial denture (chipped, cracked) was answered no, and No natural teeth of tooth fragment(s) (edentulous) was answered no. Interview 10/29/19 at 10:50 A.M. with the minimum data set nurse, Licensed Practical Nurse #120, verified that the annual comprehensive assessment dated [DATE] was incorrect concerning the resident's edentulous status. 2. Review of Resident #20's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, anxiety and muscle weakness. Review of Resident #20's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment, was on hospice services and did not have a life expectancy of six months or less. Review of Resident #20's physician orders revealed an order dated 07/22/19 for hospice services effective 06/20/19 for diagnoses of cardiac dysrhythmia, dysphagia and protein calorie malnutrition. Review of Resident #20's Hospice Initial Certification page dated 06/20/19 confirmed the resident had a limited life expectancy of six months or less if the terminal illness ran its normal course and the resident was eligible for hospice care. Interview on 10/29/19 at 3:36 P.M. with MDS Licensed Practical Nurse #120 confirmed Resident #20's MDS dated [DATE] did not accurately reflect the resident's life expectancy of six months or less. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366425 If continuation sheet Page 2 of 3 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 366425 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Village Skilled Nursing & Rehabilitation Ltd 708 Moore Road Akron, OH 44319 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview, the facility failed to ensure pureed foods were prepared according to the facility recipe and best practice guidelines. This affected four (Residents #2, #8, #19 and #22) of four residents the facility identified as requiring pureed meals. Facility census was 46. Residents Affected - Few Findings include: Review of the menu for 10/29/19 revealed the lunch meal consisted of herb lemon chicken, egg noodles, asparagus spears, dinner roll, margarine and yellow cake with chocolate frosting. Observation on 10/29/19 at 11:18 A.M. with Dietary Manager #56 and Dietitian #57 revealed [NAME] #96 preparing the pureed lunch entree which consisted of pureed herb lemon chicken. [NAME] #96 placed five scoops of chicken in the food processor then added chicken broth and pureed the mixture. After pureeing the mixture [NAME] #96 placed sliced bread in the chicken mixture one slice at a time for a total of seven slices and then pureed the mixture again. Review of the undated Pureed Lemon Herb Chicken recipe form indicated to debone the chicken and remove the skin, measure the desired amount of servings into the food processor and blend until smooth. Add broth or gravy if the product needed thinning and add commercial thickener if the product needed thickening. The liquid measure was approximate and slightly more or less may be required to achieved the desired pureed consistency. Interview on 10/29/19 at 11:30 A.M. with Dietitian #57 confirmed [NAME] #96 did not follow the recipe and should have pureed the bread separately. Dietitian #57 also confirmed the cook added seven slices of bread for five servings of chicken and this was too much bread which had the potential to alter the allotted amount of protein per each resident's three ounce serving of the pureed lemon chicken. Review of a list provided by the facility revealed Residents #2, #8, #19 and #22 where identified as requiring pureed meals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366425 If continuation sheet Page 3 of 3