Health inspection·March 11, 2025

F 0684 This deficiency represents non-compliance investigated under Complaint Number OH00161145. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365264 If continuation sheet Page 2 of 4 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 03/11/2025 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)

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 observations, record reviews, staff interviews, and review of facility policies the facility failed to provide nutritional and hydration care and services to meet the needs of one resident (Resident #108) out of three residents reviewed for nutrition and hydration and of eight facility identified eight residents requiring feeding assistance. The facility census was 107. Residents Affected - Few Findings include: Review of the medical record for Resident #108 revealed an admission date of 01/23/25 and a discharge date of 02/10/25. Diagnoses included encephalopathy (brain function impairment), dysphagia (difficulty swallowing), failure to thrive, chronic respiratory disease, hypertension, muscle weakness, atrophy (muscle wasting), anxiety, Alzheimer's disease, depression, and bipolar disorder. Review of the admission minimum data set (MDS) assessment completed 02/03/25 revealed Resident #108 had severely impaired cognition. The Resident #108 was dependent on staff for all self-care and required assistance for eating. The assessment indicated the resident had a weight of 131 pounds, had no or unknown weight loss, and required a mechanically altered diet. The Resident #108 was edentulous (lacking teeth). Review of the admission nursing assessment dated [DATE] identified the Resident #108 was admitted with a weight of 130.6 pounds. Review of the dietary orders dated 01/24/25 for Resident #108 revealed a no added salt diet, pureed texture with honey thickened liquids. Review of the nutritional assessment dated [DATE] stated the Resident #108 had advanced Alzheimer's disease and is alert only to self. admitted with no added salt diet order with pureed food texture and honey thick liquids. The assessment recommend providing fortified pudding with each afternoon meal and a frozen desert cup (Magic Cup) with each evening meal. Additionally, the assessment indicated Resident #108 had high sodium levels, was confined to bed and required total assistance with feeding with the nutritional analysis revealing the resident needed a total of 1800 calories a day with total protein needs of 78 grams; and total fluid needs of 1800 milliliters. Review of the speech therapy evaluation dated 01/28/25 revealed the Resident #108 was at risk for aspiration, further decline in function, dehydration, and pneumonia. Evaluation of pharyngeal swallow function revealed incomplete bolus formation, delayed oral transit, oral residue, delayed swallow onset, no cough or throat clear was elicited. Recommendations were close supervision for oral intake. Review of the background assessment revealed Resident #108's dentition was edentulous, the resident was non-verbal, had limited eye opening despite cues, did not follow one step commands, and had poor position when in bed due to neck position flexed to the left. Review of the plan of care dated 01/29/25 revealed the Resident #108 was at risk for altered nutrition and dehydration related to Alzheimer's disease, hypertension, weight loss, dysphagia, and poor oral intake. Resident #108 had goals that included for the resident to be free from signs and symptoms of dehydration, and to consume equal to or greater than 75 percent (%) of each meal. Interventions included a magic cup per order, no added salt, pureed texture, and honey thick liquid diet, monitoring of weight, and the monitoring oral intake. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365264 If continuation sheet Page 3 of 4 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 03/11/2025 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)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of meal intakes for Resident #108 dated 01/23/25 to 02/05/25 revealed no documentation of Resident #108's intake recorded on 01/23/25, 01/24/25, 01/28/25, 01/30/25, 02/01/25, 02/02/25, and 02/04/25. Review of the meal intake for 01/25/25 revealed the Resident #108 refused all meals. Review of the meal intake for 01/29/25 revealed 25% to 50% of meal was consumed for breakfast and dinner, and 51% to 75% for lunch. Review of the meal intake for 01/31/25 revealed 51% to 75% was consumed for breakfast and lunch, no entry for dinner. Review of the meal intake for 02/03/25 revealed 25% to 50% of meal was consumed for breakfast and lunch, dinner was refused. Review of the meal intake for 02/05/25 revealed the Resident #108 was out of the facility. Review of the emergency department medical record dated 02/03/25 and timed 10:10 P.M., revealed Resident #108 was seen for chief complaint of dehydration and high blood sodium. Review of the history and physical revealed Resident #108 has had multiple workups and hospitalizations for the same complaint and the cause is likely multifactorial. Review of the record revealed prior discussions regarding enteral feeding tube placement with family, which had been declined. Upon assessment, Resident #108 appeared to be clinically dehydrated, was minimally responsive (at baseline), and was nonverbal. Per emergency transport services, Resident #108 had a reported sodium obtained earlier in the day with a result of 165 milliequivalent's per liter (mEq/L), normal sodium range is 136 to 145 mEq/L. A repeat blood sodium level was completed in the emergency department at 11:25 P.M. with a result of 160 mEq/L. Resident #108 was admitted to the intensive care unit with a diagnosis of hypernatremia (high sodium). Review of the inpatient hospital medical record revealed Resident #108 was provided with gentle fluids with a plan to monitor laboratory tests results, consult palliative care and discuss feeding tube placement with family. A recorded weight on 02/04/25 revealed Resident #108 weighted 117.6 pounds. Resident #108 was returned to the facility on [DATE]. Interview on 02/26/25 at 10:38 A.M., Registered Dietician (RD) #400 stated the specific guidelines for feeding assistance should be listed in the care plan. RD #400 confirmed Resident #108 was dependent on staff to assist with feeding to ensure the resident's nutrition and hydration. Interview on 02/26/25 at 11:48 A.M., the Administrator confirmed the facility orders and care plan did not address the extent of feeding assistance required for Resident #108. The Administrator confirmed the weights documented in the Resident #108's medical record and verified Resident #108 was dependent on staff for feeding for both hydration and nutrition. The Administrator further confirmed Resident #108 did not have the percentage of meal intake recorded on 01/23/25, 01/24/25, 01/28/25, 01/30/25, 02/01/25, 02/02/25, and 02/04/25. Review of facility policy titled Preservation of (Activities of Daily Living) ADLs Policy, dated 12/2023 revealed if a resident is unable to carry out ADLs, he/she will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene. For these residents, care plan goals may not be stated in terms of what the resident is able to achieve, but in terms of the outcome of care and/or services provided. Review of facility policy titled Weights Protocol- Obtaining and Recording, dated 01/2024, revealed the purpose is to ensure accurate weights are obtained for residents in order to enable the appropriate evaluation of nutritional/clinical status. This deficiency represents non-compliance investigated under Complaint Number OH00162313 and Complaint Number OH00161145. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365264 If continuation sheet Page 4 of 4