Health inspection·November 8, 2023

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, staff interview, and review of the facility policy the facility failed to store, prepare, distribute, and serve food under sanitary conditions. This had the potential to affect all 65 residents residing in the facility. Findings include: 1. Observation of the kitchen on 11/07/23 from 9:00 A.M. to 9:41 A.M. with Dietary Manager #100 revealed the following concerns: Observation of the four tray line warmers revealed the water under each bin the water was milk- like in color withfloating white particles. One of the bins had dried food on the sides of the bin. Observation of the shelves directly underneath the serving area revealed there food particles, a dirty scoop, a bottle of syrup, crumbled aluminum file and a plastic bin containing non-kitchen items. Observation of the plate warmer on the left side revealed the outside of the warmer was dirty with food particles, fingerprints, and an identified dry white substance near the top of the warmer. Observation of the outside of the microwave oven revealed the handle was covered with a dry crusty like substance, and the door window had fingerprints and dried food on it. There were salt crystals scattered over the top of the microwave. Observation of the counter/work area revealed there was a bottom shelf with food particles on it, a plastic serving tray with two quarter size brown spots on it. There was also a plastic serving tray with 15 covered bowls of dry cereal which were not dated. Observation of the to of the coffee pot revealed a plastic bin with 10 individual sealed coffee packets. The plastic bin had coffee grounds all over the bottom with one loose coffee filter. Observation of the stand-alone side by side refrigerator revealed two thermometers inside with a temperature of 57 degrees Fahrenheit. The refrigerator contained the following items: 38 small cartons of chocolate health shakes, 96 cups of grape juice, 20 small cups of strawberry yogurt, 10 pre-poured cups of lemonade covered with no date, 12 pre-poured cups of tea covered with no date, two bottles of Gatorade, a can of soda and a bottle of an energy drink belonging to the facility staff. Observation of the clean dish area revealed a four-shelf unit with boxes of juices on the top shelf and clean dishes on the lower shelves. On the floor around the left front leg of the shelf there was a white bath towel with blue stains all over it. Observation of the walk-in cooler revealed the following food items: a tub of 15 hardboiled eggs shelled and covered with no date, a tray of 12 small bowls of fruit cobbler covered with no date, a tray with three bowls of pudding covered with no date. Interview on 11/08/23 at 9:42 A.M. with DM #100 confirmed all of the concerns identified during the tour. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365228 If continuation sheet Page 2 of 3 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 365228 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wilmington Nursing & Rehab 75 Hale Street Wilmington, OH 45177 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 - Many 2. Observation on 11/08/23, at 11:26 A. M. revealed Maintenance Director (MD) #170 walked past the prep area as [NAME] #120 was preparing turkey and cheese sandwiches. MD #170 was not wearing a hair net or a ball cap while in the kitchen. Interview on 11/08/23 at 11:26 A.M. with MD #170 confirmed he was not wearing a hair net or ball cap while in the kitchen. 3. Observation on 11/08/2023, at 12:10 P. M. revealed Housekeeper #180 walked into the kitchen without a hair net leaned against the food preparation table while Dietary Aide (DA) #118 was preparing lunch and asked for a cup of coffee. Staff gave Housekeeper #180 a cup of coffee and she exited the kitchen. Interview on 11/08/23 at 12:15 P.M. with DA #118 confirmed Housekeeper #180 entered the kitchen food prep area without a hairnet while food was being prepared. Review of the facility policy titled Food Preparation and Handling Policy dated 01/05/23 revealed all cold meat salads, poultry salads, egg salads, cream filled pastries and other potential hazardous foods should be prepared from chilled products and refrigerated below 41 degrees Fahrenheit immediately after preparation. Leftovers must be dated, labeled, covered, and stored in the refrigerator. The kitchen would be clean, neat, and orderly. Review of the facility policy titled Freezers and Refrigerators dated 06/09/21 revealed all refrigerator and frozen foods must be appropriately dated to ensure proper rotation by the expiration date. Refrigerators and freezers would be kept clean, free of debris and cleaned with sanitizing solution on a scheduled basis and more often as necessary. This deficiency represents non-compliance investigated under Complaint Number OH00146856. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365228 If continuation sheet Page 3 of 3