Inspection·November 3, 2023

F 0689 On [DATE] at 1:15 P.M., DON #125, Licensed Practical Nurse (LPN)/Unit Manager (UM) #119 and LPN/UM #111 completed fall risk assessments on all residents to identify all residents who were high risk for falls. Level of Harm - Immediate jeopardy to resident health or safety • Residents Affected - Few On [DATE] at 2:15 P.M., new policies were developed including Routine Resident Check Policy and High Fall Risk Common Area Policy. • On [DATE] at 2:30 P.M., an Interdisciplinary Team (IDT) meeting was held with all department heads on the new policies that were developed including Routine Resident. • Check Policy and High Fall Risk Common Area Policy as well as education by VP of Clinical Operations #130. Department heads in attendance included: the Administrator, DON #125, LPN/UM #119, LPN/UM #111, LPN/Minimum Data Set (MDS) Coordinator #131, Chaplain #132, LPN/Assisted Living (AL) DON #133, Housekeeping and Laundry Supervisor #134, Central Supply Coordinator #135, Assistant Administrator #124, Admissions Coordinator #136, Marketing and Sales Staff #137, Scheduler #138, Transportation Coordinator #139, Dietary Manager #115, Human Resources (HR) Director #140 and Activities Director #141. • On [DATE] at 3:34 P.M., education on the facility ' s Routine Resident Check Policy and High Fall Risk Common Area Policy were provided to all healthcare staff members by department heads including the Administrator, DON #125, LPN/UM #119, LPN/UM #111, LPN/MDS Coordinator #131, Chaplain #132, LPN/AL DON #133, Housekeeping and Laundry Supervisor #134, Central Supply Coordinator #135, Administrator Assistant #124, Admissions Coordinator #136, Marketing and Sales Staff #137, Scheduler #138, Transportation Coordinator #139, Dietary Manager #115, HR Director #140 and Activities Director #141. • On [DATE] at 3:35 P.M., a point of care (POC) high fall risk safety check task was placed in each resident ' s electronic medical record who was assessed as a fall risk by VP of Clinical Operations #130 for the staff to provide documentation for the additional safety checks as stated in the Routine Resident Check Policy and High Fall Risk Common Area Policy. • On [DATE] at 3:44 P.M., education binders were created by VP of Operations #129 for oncoming agency staff. • On [DATE] at 4:50 P.M., a Quality Assurance Performance Improvement (QAPI) meeting was held by the Administrator with the Medical Director via telephone and the Immediate Jeopardy plan was reviewed. The QAPI meeting was attended by DON #125, LPN/UM #119, VP of Operations #129, VP of Clinical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365162 If continuation sheet Page 2 of 9 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 365162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesleyan Village 807 West Ave Elyria, OH 44035 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 0689 Operations #130, RRN #126, Human Resources #140, LPN/AL DON #133, Assistant Administrator #124, and LPN/MDS #131. Level of Harm - Immediate jeopardy to resident health or safety • Residents Affected - Few On [DATE] at 5:26 P.M., all tasks were entered in POC for each resident who was at high risk for falls by RRN #126. • On [DATE] at 5:45 P.M., a list of high-risk for fall residents was created to place in the common areas and dining rooms, nursing stations, and medication carts by VP of Clinical Operations #130. • On [DATE] at 6:15 P.M., LPN/MDS Coordinator #131 updated all care plans of residents who were assessed as high risk for falls. • On [DATE] at 6:30 P.M., education was completed to all healthcare staff on the new policies including the Routine Resident Check Policy and the High Fall Risk Common Area Policy by facility department heads including the Administrator, DON #125, LPN/UM #119, LPN/UM #111, LPN/MDS Coordinator #131, Chaplain #132, LPN/AL DON #133, Housekeeping and Laundry Supervisor #134, Central Supply Coordinator #135, Administrator Assistant #124, Admissions Coordinator #136, Marketing and Sales Staff #137, Scheduler #138, Transportation Coordinator #139, Dietary Manager #115, HR Director #140, and Activities Director #141. • The DON or designee will audit the High Risk Fall List five times weekly for four weeks and then weekly for four weeks to ensure ongoing compliance. • The DON or designee will audit the Resident Safety Checks five times weekly for four weeks and then weekly for four weeks to ensure ongoing compliance. • All Audit findings will be submitted weekly for four weeks to the QAPI committee for review and recommendation. • Interviews were conducted on [DATE] to verify staff were educated on the new fall policies and were able to articulate the Routine Resident Check Policy and the High Fall Risk Common Area Policy. Staff interviewed included LPN #112, RN #120, Transportation Coordinator #139, State Tested Nursing Assistant (STNA) #142, Housekeeping Staff #143, STNA #144, LPN #145, Director of Rehabilitation #146, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365162 If continuation sheet Page 3 of 9 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 365162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesleyan Village 807 West Ave Elyria, OH 44035 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 0689 Certified Occupational Therapy Assistant (COTA) #147, and RN #148. Level of Harm - Immediate jeopardy to resident health or safety Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Residents Affected - Few Findings include: 1) Review of Resident #86's medical record revealed the resident was admitted to the secured memory care unit (SMCU) assisted living facility (ALF) on [DATE] with diagnoses including repeated falls, muscle weakness, and unspecified dementia. Review of Resident #86's ALF St. Louis University Mental Status (SLUMS) Examination form dated [DATE] revealed the resident scored a seven which was identified as having dementia. Resident #86's medical record revealed the resident was hospitalized on [DATE] with an admitting diagnosis of a fall. Review of Resident #86's hospital documentation dated [DATE] revealed the family elected for no invasive treatment, just medical management, due to advanced Alzheimer ' s dementia, and osteoporosis who presented to the ER from the ALF with recurrent falls. Radiological studies showed a comminuted and mildly displaced fracture of the greater trochanter. The resident hit her head and required stitches to her left eyebrow. Orthopedics had evaluated the resident and recommended no surgery at this time, pain control and toe-touch weight bearing to the left leg. Review of Resident #86's medical record revealed the resident was admitted to the skilled nursing facility (SNF) on [DATE] with diagnoses including a displaced fracture of the greater trochanter of the left femur, laceration of the left eyelid, and unspecified dementia. Resident #86's Minimum Data Set (MDS) assessment, dated [DATE], documented she needed limited assistance of two staff members for transfers, ambulation, and extensive assistance of two staff members for locomotion on and off the nursing unit, and dressing. Review of Resident #86's Fall Scale form dated [DATE] revealed the resident was at high risk for falls. Review of Resident #86's Interim Care Plan form dated [DATE] revealed the resident was cognitively impaired, required a mechanical lift for transferring and total dependence for ambulating, dressing, personal hygiene, and toilet use as well as assistance with eating and the resident used an assistive device for walking. Review of Resident #86's progress note dated [DATE] at 1:54 A.M. documented the resident arrived on [DATE] at approximately 10:00 P.M. and was alert to self. A laceration was noted above the left eyebrow measuring two centimeters (cm) which was scabbed over, and she had a left greater trochanter hip fracture with a transdermal gauze. Resident #86's plan of care, initiated on [DATE], documented a behavior problem related to noncompliance with her weight bearing status of the fractured left hip, had impaired cognition and had a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365162 If continuation sheet Page 4 of 9 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 365162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesleyan Village 807 West Ave Elyria, OH 44035 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few risk for falls. Interventions on the plan of care included to anticipate and meet Resident #86's needs, provide cueing, re-orienting and supervision as needed, and be sure Resident #86's call light was in reach, and encourage Resident #86 to ask for assistance and promptly respond to requests. Review of Resident #86's fall incident report, dated [DATE] at 1:10 P.M., documented Resident #86 had an unwitnessed fall in the dining room. The incident report stated Resident #86 needed supervision and was agitated and attempted to stand alone without staff assistance, use of assistive device, or use of a call light. Resident #86 was found on the floor. Resident #86 sustained a laceration to the right eye and pressure was applied. Resident #86 was sent to the hospital and the incident report documented the facility would reassess her safety needs upon her return to the facility. Review of Resident #86's EMT report, dated [DATE], documented a dispatch was initiated for a report of a female who fell. On contact, the resident was unresponsive to verbal stimuli. Her skin was pink, warm, and dry and her respirations were equal and unlabored. The fall was unwitnessed, and no one was on the scene who could provide the EMT with a patient medical history or details of the fall other than the resident arrived at the facility 48 hours ago and had a do not resuscitate comfort care arrest code status (DNRCCA) which allows lifesaving treatments before the patient ' s heart or breathing stops, which could not be furnished. Review of Resident #86's hospital CT scan (diagnostic imaging procedure to produce images of the inside of the body) of the head without contrast for a trauma protocol dated [DATE] revealed an acute intracranial hemorrhage including bilateral predominately frontal lobe scattered subarachnoid hemorrhages, left frontal parenchymal hematoma/contusion measuring one cm, intraventricular hemorrhage noted with layering blood along the septum pellucidum and left trigone. Review of Resident #86's hospital emergency room documentation, dated [DATE], documented the resident had a history of Alzheimer ' s, who was on Plavix, was sent over from the nursing home for a fall. It was unclear how long the resident had been down. She was found on the ground in the dining hall. Per the EMT, the nursing home was unable to provide any other history. The resident was recently sent back there from the hospital after she had a fall and had a left hip fracture. The left hip fracture was nonoperative. The resident had a hematoma to the left forehead, would open her eyes to name and would not follow commands. Upon discussion with the family, the family had elected for the resident to be comfort care and she would be admitted . During an interview on [DATE] at 9:25 A.M., the DON stated Resident #86 had a fall in the assisted living facility prior to her admission to the long-term care facility. Resident #86 had fractured her hip and due to her advanced Alzheimer's disease, the family decided to transfer her to the long-term care facility for increased supervision. The DON stated Resident #86 had sustained a fall in the long-term care facility while in the dining room and was sent to the hospital for evaluation. The family decided to initiate hospice services and Resident #86 was transferred to a hospice care facility from the hospital and did not return to the facility. During an interview with STNA #114 and STNA #113 on [DATE] at 8:30 A.M and 8:36 A.M. respectively, both stated Resident #86 was very confused and known to attempt to stand unassisted and try to ambulate. Both STNAs stated Resident #86 needed close supervision to prevent a fall. During an interview on [DATE] at 9:12 A.M., LPN/UM #111 stated staff were already in the dining room assessing Resident #86 when she got to the dining room following the resident ' s fall. She could not remember who the STNAs were at the time but stated the nurse was RN #120. LPN/UM #111 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365162 If continuation sheet Page 5 of 9 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 365162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesleyan Village 807 West Ave Elyria, OH 44035 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Resident #86 was observed trying to get out of bed by the DON on [DATE] around 9:00 A.M. and that was why the resident was put in a reclining chair in the common area at that time. LPN/UM #111 stated around 1:10 P.M. (after lunch) the resident was observed by Dietary Aide #122 walking from the reclining chair and falling approximately 20 feet away in the main dining room on the third floor. LPN/UM #111 stated the resident was observed on her side with her arm over her eye and a small amount of blood was observed on the back of her hand. Residents Affected - Few During an interview on [DATE] at 9:24 A.M., LPN #112 stated she was the nurse for Resident #86, but she was in a room passing medications to another resident, two doors down from the dining room. LPN #112 stated she was informed Resident #86 fell but she did not directly assess the resident and instead obtained anything RN #120 and LPN/UM #111 might need as they were assessing the resident. During an interview on [DATE] at 10:14 A.M., RN #120 stated she assessed Resident #86 when she was on the floor. She took vital signs and assessed the resident. She stated the resident was alert and awake and was moaning but would not answer questions. RN #120 stated the resident did not say anything coherent. The resident was lying on her left side with her arm and leg up (bent). She confirmed she was sitting at the desk of the nursing station which had a wall which obstructed the view of the dining room at the time the resident sustained the fall. During an interview on [DATE] at 10:20 A.M., STNA #121 stated she noticed Resident #86 was on the floor and remembered getting the nurse. She observed her chair was still parked at the lunch table and she must have walked to where she had fallen but she did not witness the fall. She remembered a dietary aide had come to inform them of Resident #86's fall and it took approximately one minute to get to the resident. During an interview on [DATE] at 11:15 A.M., Dietary Aide #122 stated she was in the dining room at the steam table when Resident #86 was observed getting up from the reclining chair at the table and walking. She stated she did not think anything of it and turned to finish her work at the steam table. Dietary Aide #122 stated she heard a loud bang and a thump and turned to find Resident #86 had fallen to the floor. Dietary Aide #122 stated no other nursing staff were in the dining room or near the dining room providing supervision to Resident #86, who was at risk for falls. She stated she went down to LPN/UM #111's office to inform her of the fall and then returned to her work. She was unaware of what occurred after she informed LPN/UM #111. A second interview on [DATE] at 11:25 A.M. with LPN/UM #111 confirmed Dietary Aide #122 told her Resident #86 sustained a fall in the dining room. During a telephone interview on [DATE] at 12:21 P.M., Resident #86's responsible party stated he was questioned by the hospital about his mother's care, and he did not know the extent of the injuries. He stated his mother was not alert when he visited her in the hospital. He could not understand how his mother walked across the dining room and fell with a broken hip. During an interview on [DATE] at 12:57 P.M., the DON stated they had put interventions in place for falls for Resident #86 upon admission including keep in common areas for additional staff supervision and call light in reach even though it was not documented on the immediate needs care plan. She also stated she was unaware Dietary Aide #122 had observed Resident #86 walking without assistance. She stated the dietary personnel would not know the resident's fall risk and interventions because of HIPAA (Health Insurance Portability and Accountability Act - a federal law that protects sensitive patient health information from being disclosed without the patient ' s consent or knowledge). The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365162 If continuation sheet Page 6 of 9 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 365162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesleyan Village 807 West Ave Elyria, OH 44035 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few DON stated Resident #86 was not provided one-to-one supervision, but staff would monitor the resident as she was in the common lounge/dining area. The DON confirmed no nursing staff were in the common area providing supervision to Resident #86 when she stood up from her reclining chair and walked across the common lounge/dining area and subsequently sustained a fall with fracture requiring hospitalization. During a telephone interview on [DATE] at 1:45 P.M. with the DON present, the EMT stated Resident #86 was initially not responsive on [DATE] when they found her on the floor and then she started moving around. The resident was transported to the hospital. During an interview on [DATE] at 11:21 A.M., Hospice Staff #127 stated they received Resident #86 as an inpatient for hospice services on [DATE] and she expired on [DATE]. During an interview on [DATE] at 11:50 A.M., STNA #128 stated she had observed Resident #86 in the dining room in her reclining chair on [DATE]. She stated she felt she had observed her within a couple of minutes of her fall but could not remember the exact details. She could not remember if any other staff members were in the dining room at the time of the observation and stated the nursing staff do chart right off the dining room. 2. Resident #07 was admitted on [DATE] with diagnoses including chronic severe kidney disease, depression, anxiety, anemia, osteoarthritis, hyperthyroid, lumbar disc degenerative disease of the vertebrae, gastric ulcer with a history of repeated falls, lack of coordination, muscle weakness, and need for personal assistance with personal care. A review of Resident #07's MDS assessment dated [DATE] indicated extensive assistance of two staff members was needed for bed mobility, transfers, ambulation, and locomotion. Resident #07's most recent fall assessment indicated she had a high risk for falls. Resident #07's plan of care initiated upon admission to the facility revealed a risk for falls related to impaired mobility, impaired balance, medication, incontinence and past medical history of falls. Resident #07 had a diagnosis of a fracture, anxiety, depression, chronic kidney disease, low back pain, and intervertebral disc degeneration of the lumbar region. Interventions on the plan of care revised on [DATE] documented to use a gait belt and on [DATE] to perform transfers with the use of a gait belt and two staff members. Resident #07's nursing progress note dated [DATE] revealed Resident #07 was transferred from the bed to the recliner chair by one staff member. Resident #07's knees buckled, and she was lowered to the floor. Resident #07's fall investigation report dated [DATE] indicated State Tested Nursing Assistant (STNA) #117 transferred Resident #07 from the bed to the recliner chair using a walker when Resident #07's knee became weak and STNA #117 lowered Resident #07 to the floor. The result of the investigation was to train staff to use a gait belt and two staff members for transfers. During an interview on [DATE] at 1:30 P.M., STNA #117 verified the above information and stated she was not informed Resident #07 needed two staff members and use of a gait belt for transfers. Review of the facility policy titled Falls and Fall Risk, Managing, dated 2001, revealed the policy statement was based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent residents from falling and try to minimize complication from falling. The staff, with the input of the attending physician, will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365162 If continuation sheet Page 7 of 9 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 365162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesleyan Village 807 West Ave Elyria, OH 44035 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). Monitoring subsequent falls and fall risk revealed the staff would monitor and document each resident's response to interventions or recommend whether the measures were still needed if the problem that required the intervention had resolved. If the resident continues to fall, staff will reevaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician would help the staff reconsider possible causes that may not previously have been identified. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. This deficiency represents non-compliance investigated under Compliant Number OH00146589. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365162 If continuation sheet Page 8 of 9 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 365162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesleyan Village 807 West Ave Elyria, OH 44035 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, the facility failed to ensure staff cleaned the food thermometer appropriately to prevent cross contamination or food borne illness. This had the potential to affect 19 (Residents #2, #6, #12, #14, #17, #19, #20, #32, #41, #45, #50, #52, #56, #60, #63, #69, #73, #78 and #79) residents residing on the fourth floor of the facility. The facility census was 85. Findings include: During an observation on 10/04/23 at 4:50 P.M., Dietary Aide (DA) #108 was serving the residents on the fourth floor their dinner meal. DA #108 obtained the facility thermometer located in a bucket on top of the meal cart. With the thermometer cover still in place, DA #108 dipped the thermometer in the sanitizing solution and shook off the excess solution. He then attempted to obtain the temperature of the hamburger patties on the steam table without removing the thermometer cover. DA #108 removed the cover, then checked the temperature of the hamburgers. Without sanitizing the thermometer, he proceeded to check the temperature of the potatoes. During interview on 10/04/23 at 5:30 P.M., DA #108 verified he did not know how to use the thermometer properly and did not disinfect the thermometer between meat and vegetable. DA #108 stated he was not trained to obtain the temperature of food and had only been instructed on serving the residents their meals. During an interview on 10/04/23 at 5:45 P.M., Dietary Manager (DM) #115 verified DA #108 had not been trained to obtain the temperature of the food prior to serving the food. The facility policy titled Food Serving Temperatures, undated, documented the cook is responsible to see that all foods maintain proper holding temperatures. The temperature will be taken and recorded for all hot and cold food items at each meal prior to starting tray services. Sanitize thermometer prior to taking the temperature of each item. This deficiency represents non-compliance investigated under Complaint Number OH00146212. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365162 If continuation sheet Page 9 of 9