Inspection·July 23, 2024

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to appropriately provide the physician ordered thickened liquid diet to Resident #2. This affected one resident (Resident #2) of three residents reviewed for food/nutrition. The facility identified three residents (#2, #4, and #58) who were prescribed thickened liquids. The facility census was 61. Findings include: Record review revealed Resident #2 was admitted on [DATE] to the facility with diagnoses including but not limited to cerebral infarction, chronic obstructive pulmonary disease, and diabetes mellitus. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 had intact cognition and required maximal assistance for activities of daily living. Further review of the MDS revealed that Resident #2 was on a mechanically altered therapeutic diet. Review of physician's order for July 2024 revealed Resident #2 was ordered a pureed diet with honey consistency liquids. Review of the care plan for Resident #2 revealed she was at nutritional risk related to diagnoses and mechanically altered diet, swallowing difficulties and thickened liquids. Interventions were to provide a diet as ordered. Review of the diet ticket for Resident #2 revealed her diet was a pureed diet with honey thick fluids. Observation on 07/22/24 at 12:43 P.M. in the dining room revealed Resident # 2 was given gelatin as a dessert. Resident #2's diet ticket located on the table revealed Resident #2 was to receive honey thick liquids. State Tested Nursing Assistant (STNA) #211 verified Resident #2 had gelatin and was on honey thickened liquids at the time of observation. Interview on 07/22/24 at 12:44 P.M. with Speech Therapist (ST) #401 revealed gelatin can be given to certain residents when they are on honey thickened liquids. ST #401 stated he was not the regular ST in the building and cannot state if Resident #2 was allowed to have gelatin. Interview on 07/22/24 at 1:10 P.M. with [NAME] #213 revealed thickened liquids do not get gelation, ice cream or popsicles. (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: 366425 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 07/23/2024 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)