Health inspection·April 23, 2024

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** Based on facility job description review, clinical record review, review of facility investigation, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure a beverage was provided to residents in a form to meet the resident's individual need, which resulted in harm, evidenced by aspiration (when food, drink, or foreign objects are breathed into the lungs) requiring hospitalization for one of three residents reviewed (Resident 1). Findings Include: Review of the facility's job description for a dietary aide with an effective date of August 24, 2023, revealed Responsible for setting, servicing and cleaning the dining rooms; between meals assists with meal preparation Follows established procedures during food preparation, meal service and clean up. On September 15, 2023, Employee 3 (Dietary Aide) signed an acknowledgement of her dietary aide job description. Review of Resident 1's clinical record revealed that he was admitted to the facility on [DATE], with diagnoses that included dysphagia (difficulty swallowing), Type 2 Diabetes Mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), Parkinsonism (an umbrella term that refers to brain conditions that cause slowed movements, stiffness, and tremors), and hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood). Review of Resident 1's physician orders revealed a diet order with a start date of April 11, 2024, for a carbohydrate controlled diet, mechanical soft texture, honey/moderate consistency. Review of Resident 1's meal ticket for dinner on April 11, 2024, revealed that he was to be served honey thick, diet iced tea. Review of Resident 1's nursing progress note dated April 11, 2024, revealed that Resident 1's family member came out of the Resident's room asking for a nurse to come check on Resident 1, stating that he was not acting right. The family member stated she wasn't sure if it was due to Resident 1 drinking his drink or if he was having another TIA (Transient ischemic attack - mini stroke). The family member stated that Resident 1 had taken a few sips of his iced tea and then began to cough. The family member then stated she realized that the iced tea that was on Resident 1's dinner tray was not thickened. Resident 1 became unresponsive and the family member notified the nurse. (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 3 Event ID: 395445 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 395445 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Messiah Lifeways at Messiah Village 100 Mount Allen Drive Mechanicsburg, PA 17055 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)