Inspection·March 26, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility documents, the facility failed to ensure they had a three-day emergency supply of food as required. This had the potential to affect all 54 residents. The facility identified no residents as receiving nothing by mouth. The census was 54. Findings include: Observation during initial tour of the kitchen on 03/25/24 from 8:03 A.M. to 8:25 A.M. with Dietary [NAME] (DC) #355 and Dietary Aide (DA) #356 revealed a minimal supply of foods in dry and cold storage areas of the kitchen. The walk-in cooler and freezer revealed the shelves held minimal foods available to cook for the meals. The bread rack had multiple empty shelves with a few packages of bread products. There was no instant powdered milk or canned meat items available for an emergency food supply. Dietary Aide #356 at the time of observation confirmed the facility did not have a three-day emergency supply of food. Interview on 03/25/24 at 8:39 A.M. with Dietary Manager (DM) #350 confirmed the facility did not have a three-day supply of food on hand in the facility. She stated there had never been a three-day supply of food since she started at the facility six months ago. DM #350 stated she had gotten a quote from the food vendor on everything she needed for a three-day supply of food and had presented it to the Administrator. DM #350 stated the Administrator would get back to her. Review of the facility document Three Day Emergency Menu, dated 12/06/22, revealed for all three days for breakfast corn beef hash, assorted cereals, orange juice, instant powdered milk and spring water would be served. For day one lunch, chili beef with beans, saltines, wheat bread, mandarin oranges, instant powdered milk, and spring water and for dinner peanut butter and jelly sandwiches, carrots, potato chips, apple sauce and [NAME] cookies, powdered milk, and spring water would be served. For day two lunch, chicken and dumplings, carrots, wheat bread, fruit cocktail, instant milk, and spring water and for dinner sloppy joe sandwich, green peas canned, pretzels, chilled peaches, [NAME] cookies, instant powdered milk, and spring water would be served. For day three lunch, beef stew, green beans, graham crackers, wheat bread, pineapple chunks, instant powdered milk and spring water and for dinner, tuna salad sandwich, beets, potato chips, fruit cocktail, [NAME] cookies, instant powdered milk and spring water would be served. Review of the Three Day Emergency Menu and interview on 03/25/24 at 4:33 P.M. with DM #350 confirmed the facility couldn't provide the emergency menu since the facility did not have powdered milk, canned meats, potato chips, pretzels, and Loorna [NAME] cookies in stock. (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: 366270 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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)