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 Page 1 of 5 365264 365264 06/12/2024 O'Neill Healthcare Bay Village 605 Bradley Rd Bay Village, OH 44140

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the quarterly nutritional assessment dated [DATE] revealed that Resident #29 received supplements to include fortified pudding at lunch, yogurt at breakfast and ice cream. The registered dietitian recommended to continue current diet and supplements. Review of the lunch diet ticket for Resident #29 revealed that the resident should have received fortified pudding at lunch. Interview on 06/11/24 at 3:47 P.M. with Administrator revealed an audit of tray tickets were completed and since Resident #29 did not have a physician's order for fortified pudding because it was discontinued in May 2024, the facility took the preference off the ticket the previous night. 4. Review of the medical record for Resident #60 revealed an admission date of 02/08/24. Diagnoses included but not limited to chronic obstructive pulmonary disease, depression, and malignant neoplasm of unspecified part of bronchus or lung. Review of the physician's order for June 2024 revealed that Resident #60 ordered fortified pudding at lunch as supplement. Review of the dietary note dated 06/06/24 at 10:42 A.M. revealed the registered dietitian recommended fortified cereal at breakfast, pudding at lunch, and ice cream at dinner. Review of the lunch diet ticket for Resident #60 revealed that the resident should have received fortified pudding at lunch. 5. Review of the medical record for Resident #94 revealed an admission date of 04/18/20. Diagnoses included but not limited to chronic kidney disease, major depressive disorder, and dysphagia. Review of Resident #94's care plan dated 10/13/22 revealed that he was at risk for altered nutrition/hydration related to skin impairment and diagnoses. Interventions included but were not limited to honoring food preferences as able. Review of the lunch diet ticket for Resident #94 revealed that the resident should have received fortified pudding at lunch. Observation of tray line on 06/10/24 from 11:30 A.M. through 1:02 P.M. revealed that the facility ran out of fortified pudding halfway through meal service. Interview on 06/10/24 at 12:20 P.M. with Dietary Aide #347 revealed that there was no more fortified pudding for Residents #16, #27, #29, #60, and #94. Review of the facility policy titled, High Calorie/High Protein Diet, dated 2006, revealed that the following suggestions are intended for people who need to increase calories to maintain or gain weight. This deficiency represents non-compliance investigated under Master Complaint Number OH00154405. 365264 Page 2 of 5 365264 06/12/2024 O'Neill Healthcare Bay Village 605 Bradley Rd Bay Village, OH 44140

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, taste test and recipe review, the facility failed to serve pureed foods at a smooth consistency for safe swallowing for Residents #18, #66, and #110. This affected three residents (18, #66 and #110) out of three residents who were prescribed pureed diets. The facility census was 111. Findings include: Observation of tray line on 06/10/24 from 11:30 A.M. through 1:02 P.M. revealed that the puree peas appeared to be lumpy. A taste test of pureed peas revealed that there were pieces of the pea shells and were not smooth in consistency. A taste test on 06/10/24 at 11:42 A.M. with Speech Therapist (ST) #404 verified that the pureed food was not a smooth consistency. Review of the facility's spreadsheet for the day on 06/10/24 at the bottom revealed pureed foods should hold their shape on a spoon and smooth texture. This deficiency represents non-compliance investigated under Master Complaint Number OH00154405. 365264 Page 3 of 5 365264 06/12/2024 O'Neill Healthcare Bay Village 605 Bradley Rd Bay Village, OH 44140

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview, and record review, the facility failed to ensure resident food allergies and preferences were honored. This affected two residents (#43 and #111) who had food allergies and one resident (#69) for food preferences. This had the potential to affect 110 residents out of 111 residents who received meals from the facility kitchen. The facility identified one resident (#30) who received nothing by mouth. The facility census was 111. Findings include: 1. Review of the medical record for Resident #43 revealed an admission date of 11/11/22. Diagnoses included but not limited to hemiplegia affecting the left side, anxiety disorder, and depression. Review of the physician's order for June 2024 revealed that Resident #43 was allergic to chocolate. Review of the lunch diet ticket for Resident #43 revealed that the resident was allergic to chocolate. Observation of tray line on 06/10/24 at 12:24 P.M. revealed Dietary Aide #407 checked Resident #43's tray and put it into the food cart. When asked, Dietary Aide #407 pulled the tray out of the food cart and verified that Resident #43 had two chocolate chip cookies on his tray. Dietary Aide #407 verified the tray had cookies on it and replaced the cookies with fruit. 2. Review of the medical record for Resident #111 revealed an admission date of 05/23/24. Diagnoses included but not limited to dementia, osteoarthritis, and atherosclerotic heart disease. Review of the lunch diet ticket for Resident #111 revealed that the resident the resident was allergic to wheat. Observation of tray line on 06/10/24 at 12:21 P.M. revealed Dietary Aide #407 checked Resident #111's tray and put it into the food cart. When asked, Dietary Aide #407 pulled the tray out of the food cart and verified that Resident #111 had two chocolate chip cookies on her tray. Dietary Aide #407 verified the tray had cookies on it and replaced the cookies with fruit. 3. Review of the medical record for Resident #69 revealed an admission date of 01/06/23. Diagnoses included but not limited to quadriplegia, chronic obstructive pulmonary disease, anxiety disorder, and major depressive disorder. Review of Resident #69's care plan dated 01/11/23 with a revision date of 10/12/23 revealed that she was at risk for altered nutrition/hydration related to low albumin and diagnoses. Interventions include but are not limited to encouraging high protein foods such as meats, almond milk, eggs, cheese and yogurt. Review of the lunch diet ticket for Resident #69 revealed that the resident the resident was to receive almond milk. Observation of tray line on 06/10/24 at 12:27 P.M. revealed Dietary Aide #407 checked Resident 365264 Page 4 of 5 365264 06/12/2024 O'Neill Healthcare Bay Village 605 Bradley Rd Bay Village, OH 44140

F 0806 Level of Harm - Minimal harm or potential for actual harm #69's tray and Dietary Aide #407 asked for almond milk, and Dietary Aide # 347 verified that there was no almond milk. This deficiency represents non-compliance investigated under Master Complaint Number OH00154405. Residents Affected - Few 365264 Page 5 of 5