Health inspection·April 24, 2024

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on review of the facility menus and spreadsheets, observation and interview, the facility failed to follow menus as written and failed to offer appropriate portion sizes of foods on the menu to ensure residents received adequate nutrition. This had the potential to affect all residents receiving meals from the kitchen excluding one resident (Resident #16) the facility identified as eating nothing by mouth. The facility census was 97. Findings include: Review of the facility menu dated 04/17/24 revealed the lunch meal would consist of barbeque pork loin, cowboy baked beans, and buttered spinach. Review of the facility menu and spreadsheets for the dinner meal on 04/17/24 revealed tuna salad sandwiches with four ounces of tuna per sandwich would be served for dinner. Interview was conducted on 04/17/24 at 12:30 P.M. with Ombudsman #900 and #901 who were present in the facility at the time of the interview. Ombudsman #900 and #901 revealed there were many food complaints from the residents including hot foods being served cold, the foods not being palatable and the dietary staff not serving what was on the menu. Observation on 04/17/24 at 12:45 P.M. during tour of the kitchen revealed pork loin sitting in the cooler and no pork loin on the trayline for the lunch meal. Interview on 04/17/24 at 1:30 P.M. with the Assistant Kitchen Manager (AKM) #818 revealed the pork loin for the lunch meal was not done cooking so she pulled it out of the oven and placed it in the cooler. AKM #818 said stuffed peppers would be served in place of the pork loin. AKM #818 verified serving stuffed peppers was not on the menu for the lunch meal. Observation made on 04/17/24 at 4:00 P.M. of dinner tray line revealed AKM #818 was serving tuna salad sandwiches which only had three ounces of tuna salad on them and not the four ounces of tuna indicated on the spreadsheets in order to meet nutritional needs of the residents. Interview on 04/17/24 at 4:01 P.M. with [NAME] #711 confirmed she only used the three ounce scoop to make the tuna salad sandwiches and not the four ounce scoop as instructed on the menu/spreadsheets. Interview on 4/18/24 at 4:03 P.M. with the Dietary Manager (DM) #796 revealed kitchen staff do not follow the menus provided to them for the meals so the residents are served foods not on the planned Page 1 of 3 366195 366195 04/24/2024 Beeghly Oaks Center for Rehabilitation & Healing 6505 Market Street Youngstown, OH 44512

F 0803 Level of Harm - Minimal harm or potential for actual harm menus. DM #796 also confirmed [NAME] #711 only served three ounces of tuna on the tuna salad sandwiches and not the four ounces of tuna as directed on the menu/spreadsheets. This deficiency represents non-compliance investigated under Master Complaint Number OH00152706 and Complaint Number OH00152341. Residents Affected - Many 366195 Page 2 of 3 366195 04/24/2024 Beeghly Oaks Center for Rehabilitation & Healing 6505 Market Street Youngstown, OH 44512

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to ensure palatable foods were served at meals. This had the potential to affect all residents receiving meals from the kitchen excluding one resident (Resident #16) who the facility identified as eating nothing by mouth. The facility census was 97. Residents Affected - Many Findings include: Interview was conducted on 04/17/24 at 12:30 P.M. with Ombudsman #900 and #901 who were present in the facility at the time of the interview. Ombudsman #900 and #901 revealed there were many food complaints from the residents including hot foods being served cold, the foods not being palatable and the dietary staff not serving what was on the menu. Interviews conducted intermittently throughout the survey from 04/17/24 to 04/24/24 with Residents #1, #15, #17, #20. #21, #42, and #58 revealed they were unhappy with the food. They stated the food did not always taste good and at times hot foods were served cold. Observation was conducted on 04/18/24 at 11:15 A.M. of the kitchen tray line and revealed all food being served for lunch from the trayline met minimum temperature requirements for food safety. Observation was conducted on 04/18/24 at 11:42 A.M. of a test tray containing lasagna, green beans, and cherry crisp. The temperatures were taken by the Dietary Manager (DM) who was using a calibrated thermometer and revealed the lasagna was 140 degrees Fahrenheit (F), the green beans were 110.4 degrees F, tasted cold and had no flavor, and the cherry crisp was 86 degrees F. Interview on 04/18/24 at 11:45 A.M. with the DM verified the green beans were cold and had no flavor to them. DM confirmed the green beans were not served at a palatable temperature. This deficiency represents non-compliance investigated under Master Complaint Number OH00152706 and Complaint Number OH00152341. 366195 Page 3 of 3