Health inspection·June 1, 2023

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 observations, interviews, record review, and facility policy review, the facility failed to provide the physician ordered liquid consistency to one resident (#3) of two residents reviewed for diet waivers. The facility census was 29. Findings include: Record review for Resident #3 revealed an admission date of 01/07/23. Diagnoses included vascular dementia, pneumonitis due to inhalation of food and vomit, pharyngeal phase dysphagia (difficulty in swallowing), moderate protein calorie malnutrition, and respiratory failure with hypoxia (lack of adequate oxygen in the blood). Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was severely cognitively impaired, independent with staff assistance for set up for eating?, on a prescribed weight loss regimen, and had no swallowing concerns. Review of facility document titled Determination to Ignore Medical Advice of a Modified Diet or Fluids and Release of Liability, dated 12/23/22, revealed the speech therapist had recommended honey thick liquids for Resident #3; however, Resident #3 was requesting regular water, regular coffee, and regular tea on occasion despite the high risk for serious negative health outcome, such as aspiration, which could result in serious pulmonary complications and possible death. Resident #3 acknowledged by signature on 12/23/22 a full understanding of the risks of the decision to not follow the diet as ordered and released the liability from the facility for not following medical advice. Review of the care plan dated 01/10/23 revealed Resident #3 was at risk for a decline in nutritional status due to dementia and dysphagia. Interventions included provide diet as ordered. Review of the care plan dated 01/11/23 revealed Resident #3 was at risk for aspiration related to the dietary waiver signed to allow thin coffee, hot tea, and water despite order for honey thick liquids. Interventions included monitoring for signs and symptoms of aspiration, which included fever, coughing, gurgling voice at or after a meal, and excessive drooling. Record review of the active physician orders for Resident #3 revealed a no added salt (NAS) mechanical soft honey thick liquids diet dated 1/18/23. Review of dietary breakfast tray card dated 05/30/23 revealed Resident #3 was on a regular mechanical soft honey thick liquid diet. (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: 366453 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 366453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shepherd of the Valley Poland 301 West Western Reserve Road Poland, OH 44514 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)