Health inspection·June 12, 2024

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review the facility failed to provide fortified pudding to residents as an intervention for maintaining weight, wound care and/or preventing weight loss. The affected five residents (#16, #27, #29, #60 and #94) out of 15 residents who were to receive fortified pudding at lunch either by physician order or dietitian recommendation. The facility census was 111. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 09/27/18 and a readmission date of 10/13/20. Diagnoses included but not limited to dementia, personal history of malignant neoplasm of large intestine, and diabetes mellitus. Review of the physician's order for June 2024 revealed that Resident #16 was ordered fortified pudding at lunch daily. Review of Resident #16's care plan dated 04/11/24 revealed that he was at risk for altered nutrition/hydration related to diagnoses. Interventions included but not limited to encouraging intake of high protein foods and giving fortified pudding at lunch. Review of the lunch diet ticket for Resident #16 revealed that the resident should have received fortified pudding at lunch. 2. Review of the medical record for Resident #27 revealed an admission date of 09/23/20. Diagnoses included but not limited to chronic obstructive pulmonary disease, depression, and anxiety disorder. Review of the physician's order for June 2024 revealed that Resident #27 ordered fortified pudding at lunch for weight loss. Review of Resident #27's care plan dated 12/14/24 revealed that she was at risk for altered nutrition/hydration related to diagnoses. Interventions included but are not limited to giving fortified cereal at breakfast, giving fortified pudding at lunch and fortified pudding at dinner. Review of the lunch diet ticket for Resident #27 revealed that the resident should have received fortified pudding at lunch. 3. Review of the medical record for Resident #29 revealed an admission date of 09/22/23. Diagnoses included but not limited to chronic obstructive pulmonary disease, depression, and diabetes mellitus (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 5 Event ID: 365264 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 365264 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Neill Healthcare Bay Village 605 Bradley Rd Bay Village, OH 44140 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)