Inspection·June 6, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 06/05/23 at 4:40 P.M. revealed State Tested Nursing Assistant (STNA) # 639 was standing up and feeding Resident #35 in the unit dining room. Interview on 06/05/23 at 5:00 P.M. with STNA #639 confirmed she fed Resident #35 while standing up and stated normally Resident #35 only needed some assistance with a couple bites but today needed more assistance. 3. Review of medical record for Resident #42 revealed an admission date of 06/29/22. Diagnoses included dementia, psychosis (mental disorder characterized by a disconnection from reality), weakness, age related physical debility, abnormal weight loss, and glaucoma (group of eye diseases that cause vision loss). Review of 04/17/23 annual MDS 3.0 assessment revealed Resident #42 had severe cognition deficit and required supervision with set up for eating. Review of physician orders for Resident #42 revealed an order dated 06/29/22 for a regular diet, regular texture, and regular/thin consistency diet. Review of care plan dated 06/29/22 revealed Resident #42 had a self-care performance deficit related to debility. Interventions included encourage participation to the fullest extent possible with each interaction. Observation of the memory care unit dining room on 06/05/23 at 1:04 P.M. revealed STNA #618 was feeding Resident #42 while standing up. Interview on 06/05/23 at 1:18 P.M. revealed STNA #618 confirmed she had stood while feeding Resident #42 and stated it all depended on if there was an empty chair if she stood or sat to feed residents. 4. Review of medical record for Resident #45 revealed an admission date 07/16/22. Medical diagnoses included: heart failure, muscle weakness, unspecified dementia, cognitive communication deficit, dysphagia, altered mental status, and other lack of coordination. Review of Resident #45's physician order dated 09/08/22 revealed an order dated 09/08/22 for a regular diet, mechanical soft texture, 1800 milliliter fluid restriction. Review of quarterly MDS 3.0 assessment dated [DATE] revealed Resident #45 was severely impaired cognitively and required extensive assist of one for eating. Observation on 06/05/23 at 12:21 P.M. revealed STNA #648 was observed feeding Resident #45 in the unit dining room standing up while a stool on wheels was beside her. Interview on 06/05/23 at 12:33 P.M. with STNA #648 confirmed she had stood while feeding Resident #45 and stated at her prior place of employment she was not allowed to sit but instead had to crouch. Interview with the Director of Nursing on 06/05/23 at 5:45 P.M. confirmed staff should be sitting while feeding residents and he was going to in-service staff and order more stools. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 2 of 11 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 365494 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapel Hill Community 12200 Strausser St NW Canal Fulton, OH 44614 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 0550 Level of Harm - Minimal harm or potential for actual harm Review of facility policy Residents Rights, revised 10/14/19, revealed residents had the right to be treated with respect and dignity. This deficiency represents non-compliance investigated under Complaint Number OH00143294. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 3 of 11 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 365494 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapel Hill Community 12200 Strausser St NW Canal Fulton, OH 44614 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on review of the facility job description, personnel record review, and staff interview, the facility failed to ensure a qualified person was designated to serve as the director of food and nutrition services. This had the potential to affect all 68 residents residing in the facility. Findings Include: Review of the undated facility job description for Director of Dining Services revealed the Director of Dining Services was responsible for controlling and supervision the dining services to ensure the provision of quality of food service and nutritional care. Essential functions included ensuring cleanliness and sanitary work habits of dietary personnel, inspecting the entire department regularly to ensure safe, sanitary, and orderly conditions were maintained, and maintaining required records and reports. Requirements included: a bachelor's degree was preferred, two to three years of supervisory experience in hospital or long term care facility department was desirable, and applicant must have either a degree in dietetics or related area from a university/college approved by Commission on Dietetic Registration preferred, Dietetic Technician Registered certification desirable, possess a certified dietary manager certification, or has a similar national certification for food service management and safety from a national certifying body, and must obtain and maintain mandatory state/federal requirements and certifications for practice. Review of the personal file for Director of Dietary (DD) #701 revealed the DD #701 was not a certified dietary manager or certified food service manager. DD #701 did not hold an associate's or higher degree in food service management or in hospitality. DD #701 did not have two or more years of experience in the position of director of food and nutrition services in a nursing facility setting. DD #701 had completed a course of study in food safety on 02/28/14, however, the certification expired on 02/28/19. DD #701 was noted to have over 20 years of experience as a cook in a nursing home or independent living kitchens. Review of the list of staff for the facility revealed the facility employed a part time registered dietician who worked at the facility two days a week. Interview on 03/16/23 at 10:30 A.M. with the Administrator verified the lack of necessary qualifications for DD #701 to serve as the Director of Dining Services, and the RD only worked at the facility two days a week This deficiency resulted from incidental findings during the investigation of Complaint Number OH00143294. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 4 of 11 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 365494 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapel Hill Community 12200 Strausser St NW Canal Fulton, OH 44614 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 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 observations, interviews, facility food temperature logs review, and facility policy, the facility failed to ensure food items were served at palatable temperature which had the potential to affect all 67 residents who received food from the kitchen. The facility identified Resident #67 as receiving nothing by mouth. The facility census was 68. Residents Affected - Many Findings include: Interview on 06/05/23 at 10:34 A.M. revealed Resident #61 felt the food was cold sometimes. Observation was conducted on 06/05/23 from 5:00 P.M. to 5:40 P.M. of dietary staff plating the lunch meal from a steam table in the second-floor unit dining room. As the tray line neared an end, the surveyor requested a test tray be prepared and placed on the second-floor room tray food cart. Observation was made as the test tray was prepared, placed on the cart at 5:31 P.M., transported, and arrived at 5:32 P.M. to second floor room location where those room trays were going to be passed. The test tray remained on the cart in view of the surveyor, until all other trays were distributed to residents. The test tray was removed from the cart at 5:36 P.M. by Dietary Director (DD) #701 who confirmed with a facility thermometer the turkey was 120 degrees Fahrenheit (F), mashed potatoes were 120 degrees F, the beets were 119 degrees F, the milk was 46.9 degrees F, and the coffee was 153 degrees F. Immediately following confirmation of the test tray temperatures, the surveyor taste-tested the turkey, mashed potatoes, and beets. All items were found to have appropriate texture and flavor but were not at a palatable temperature since all items did not taste hot and were barely warm. At the time of observation, DD #701 confirmed the food items could be warmer, the facility used to have plate warmers in the past, and she had never done a test tray to ensure food was being served at an appropriate temperature. Interview on 06/06/23 at 9:36 A.M. with Social Services #704 revealed the food could be better and the biggest complaint from residents was the food was cold. Interview on 06/06/23 at 10:05 A.M. with Licensed Practical Nurse #315 revealed the food was cold especially at dinner and some items, like fish, don't appear to be cooked thoroughly. Interview on 06/06/23 at 1:40 P.M. revealed Residents #57 and #58 felt the food was cold when they received their room trays. Interview on 06/06/23 at 2:45 P.M. revealed STNA #647 had heard lots of food complaints from residents, which were mostly directed at the dinner meal with items being cold and not being cooked correctly. Review of the facility concern log from 03/20/23 to 05/31/23 revealed on 04/12/33 Residents #57 and #58 felt food was often served cold in their rooms and were told to go to the unit dining room for warmer food. Review of May 2023 food temperature logs in the main kitchen revealed dinner food temperatures had only been recorded nine out of 31 dinners served to the residents. Review of May 2023 food temperature logs in the ground floor servery revealed dinner food temperatures had only been recorded seven out of 31 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 5 of 11 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 365494 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapel Hill Community 12200 Strausser St NW Canal Fulton, OH 44614 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of May 2023 food temperature logs in the second floor servery revealed dinner food temperatures had only been recorded 11 out of 31 days. Interview on 06/06/23 at 11:31 A.M. with the Director of Dietary #701 confirmed the food temperature logs for meal items served out of the main kitchen and in the servery on the ground floor and second floor had many days where the dinner meal items were not recorded. Since the meal item temperatures had not been recorded for those meals, she could not ensure those items were properly cooked. Director of Dietary #701 stated it was her job to ensure temperatures of meal items were being recorded but she had fallen behind on checking them. Review of facility policy Food and Drink, revised 12/17/18, revealed food and drink would be palatable, attractive, and at a safe and appetizing temperature. The temperatures of the food items would be taken and properly recorded for each meal. Hot food items would be greater than 135 degrees Fahrenheit (F) when leaving the hot holding serving system. Cold food temperatures would leave the serving area at or below 41 degrees F. This deficiency represents non-compliance investigated under Complaint Number OH00143294. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 6 of 11 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 365494 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapel Hill Community 12200 Strausser St NW Canal Fulton, OH 44614 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation and interview, the facility failed to ensure adaptive eating equipment was provided at meals for Resident #21 and Resident #33. This affected two residents (#21 and #33) of six residents reviewed for dining services. The facility census was 68. Residents Affected - Few Findings include: 1.Review of medical record for Resident #21 revealed an admission date of 07/06/22. Diagnoses included abnormal posture, anxiety disorder, bipolar disorder, cognitive communication deficit, dysphagia, unspecified dementia major depressive disorder, and Parkinson's disease. Review of the 04/05/23 annual Minimum Data Set (MDS) 3.0 assessment revealed Resident #21 had severe cognitive deficit, required supervision with one-person physical assist for eating, had no swallowing concerns, and was on a mechanically altered diet. Review of Resident #21's physician order dated 07/12/22 revealed an order for regular diet, mechanical soft texture, no bread or rice, pureed meat with divided plate and weighed silverware. Review of 07/07/22 care plan revealed Resident #21 had an activity of daily living deficit related to progressive diagnoses with an intervention of staff supervision with meals. Review of 07/11/22 care plan revealed Resident #21 had an increased risk of alteration in nutrition related to Parkinson's disease, needed a mechanically altered diet due to dysphagia, and sometimes refused adaptive utensils and requested regular utensils. Interventions included adaptive equipment per occupational therapy and may offer regular utensils upon resident request. Review of occupational therapy note dated 10/30/22 revealed resident #21 displayed 75 percent spillage while using regular utensils and improved ability and coordination while using adaptive utensils. Review of occupational therapy note dated 11/07/22 revealed resident #21 did not have correct adaptive equipment during breakfast and the occupational therapy assistant educated staff for the need for the adaptive equipment. Kitchen staff stated, I couldn't find it. Review of occupational therapy note dated 11/10/22 revealed resident #21 did not have proper adaptive equipment and displayed increased spillage and difficulty bringing spoon to mouth with regular utensils. Observation on 06/05/23 from 11:59 A.M. to 1:20 P.M. revealed Resident #21 was sitting at a table in the unit dining room. Resident #21 had a divided plate and regular silverware. While self feeding, Resident #21's hands shook and had difficulty getting the puree spaghetti on the regular spoon and then getting the spoon with the puree spaghetti into Resident #21's mouth. Interview at the time of observation revealed Licensed Practical Nurse #315 confirmed Resident #21 had not received weighted silverware as ordered for lunch. Observation on 06/06/23 from 8:56 A.M. to 9:30 A.M. revealed Resident #21 was sitting at a table in the unit dining room and had a divided plate with eggs and oatmeal and regular silverware. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 7 of 11 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 365494 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapel Hill Community 12200 Strausser St NW Canal Fulton, OH 44614 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 0810 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few table area around the divided plate was observed to have spilled oatmeal and egg and particles of egg were observed on Resident #21's left hand. State Tested Nursing Assistant (STNA) #648 confirmed there were no adaptive utensils and stated she was not sure if Resident #21 was to receive adaptive equipment. STNA #648 added there was no adaptive silverware available today. 2. Review of Resident #33 medical record revealed an admission date of 03/24/23. Diagnoses included encephalopathy, sever protein calorie malnutrition, dysphagia, dementia, cognitive communication deficit, Alzheimer's disease, anxiety disorder, and depression. Review of physician orders revealed Resident #33 had an order dated 04/25/23 for regular diet, pureed texture, and thin liquids. Review of 05/09/23 quarterly Minimum Data Set (MDS) revealed Resident #33 had severe cognitive impairment, required total dependence of one person assist for eating, had no swallowing concerns or significant weight changes and was on a mechanically altered diet. Review of dietary note dated 05/15/23 revealed the family of Resident #33 had requested a small rubber spoon be used to feed her mother and no knife be offered at meals, and the facility would honor the request. Review of 03/28/23 care plan revealed Resident #33 had an activity of daily living deficit related to muscle weakness and age-related debility. Interventions included staff would provide total assistance with eating. Review of 03/30/23 care plan revealed Resident #33 was at increased risk for alteration in nutrition related to diagnoses of dementia, severe protein calorie malnutrition, and dysphagia, on a mechanical altered diet, and required increased nutrition for wound healing. Interventions included provide and serve diet as ordered, and facility would provide small rubber spoon with meals and no knife per daughter request. Review of dinner dietary tray card, dated 06/03/23, revealed Resident #33 was on a blended diet and was not to receive a knife and wanted a small rubber spoon. Interview on 06/05/23 at 3:21 P.M. with Dietitian #428 revealed Resident #33 was to receive small spoons at meals at the request of family and when the adaptive equipment was a family request, it was put on the tray card and in the care plan but was not put in as an order. Observations conducted on 06/05/23 from 4:40 P.M. to 5:40 P.M. revealed Resident #33 was sitting at a table in the unit dining room. Sitting in front of Resident #33 was a napkin with a regular fork, knife and regular spoon on top of it. STNA #616 took a large spoonful of mashed potatoes and tried to feed Resident #33 and Resident #33 would not open mouth wide enough for the spoonful of mashed potatoes. STNA #33 then took half of the mashed potatoes off of the spoon and was then able to get the mashed potatoes into Resident #33's mouth. Interview at the time of observation with STNA #616 revealed she did not think Resident #33 received any adaptive equipment since Resident #33 had been receiving regular silverware. Licensed Practical Nurse #329 was observed to take over feeding Resident #33 and used a fork to feed Resident #33. Observed in the utensils tray sitting on a cart in the unit dining room was two small pink spoons. Review of the undated facility policy Adaptive (Assistive) Eating Devices revealed the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 8 of 11 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 365494 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapel Hill Community 12200 Strausser St NW Canal Fulton, OH 44614 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 0810 would provide special eating equipment and utensils as appropriate. Level of Harm - Minimal harm or potential for actual harm This deficiency represents non-compliance investigated under Complaint Number OH00143294. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 9 of 11 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 365494 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapel Hill Community 12200 Strausser St NW Canal Fulton, OH 44614 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, record review and interview, the facility did not ensure food was stored, prepared and served under sanitary conditions. This had the potential to affect 67 residents who received food from the kitchen. The facility identified one resident (#67) as receiving nothing by mouth. The facility census was 68. Findings include: 1. Observation of the facility kitchen on 06/05/23 from 2:25 P.M. to 3:20 P.M. with the Director of Dietary (DD) #701 revealed the following concerns verified at the time of observation by DD# 701: The microwave in the kitchen area had an accumulation of spattered debris on the walls, inside of the door, and the inside top of unit; In the walk-in cooler, there was one five-pound container of sour cream with an open date of 5/18/23 and best if used by date of 5/29/23. One 30-pound bucket of sliced strawberries in syrup which was one fourth full, had a layer of white mold growing in it; In the dry storage area, the three, plastic bulk containers of oats, flour, and sugar had an accumulation of debris on the lids and bases of the units; In the room containing the dishwasher, both the floor and the top of the dishwasher had an accumulation of dirt and debris; The bottom shelf of the steam table closest to the wall had an accumulation of red rust-colored dry particles next to the meal sheet pans which were being stored on that shelf; The four black serving carts revealed an accumulation of dirt and debris on the shelves and base of the units; The floor of the kitchen had an accumulation of dirt and debris around most of the perimeter of the floor. Review of the undated facility policy Food Storage revealed food would be stored in an area that was clean. Review of undated facility policy 'Food Safety and Sanitation revealed the dry storage areas would be clean, leftovers would be used within three days, perishable foods with expiration dates would be used or discarded prior to the use by date on the package, when a food package was opened the food item would be marked to indicate the open date, which would be used to determine when to discard the food. 2. Observation was conducted on 06/05/23 from 2:25 P.M. to 3:20 P.M. with Dietary Employee (DE) #418 as DE #418 demonstrated cleaning of the food processor parts that would be used in making pureed food items for the residents on pureed diets. DE #418 dipped the parts directly into the sanitizing solution in the sanitizing compartment of the three compartment sink skipping over the wash and rinse steps in that process. DE #418 did not test the level of sanitizer before dipping the parts into it nor was there a log of sanitizing solution levels in the three compartment sink area. Interview on 06/06/23 at 11:31 A.M. with DD #701 confirmed there was no log of recorded sanitizer solution levels since she didn't know she had to keep one and without the log DD #701 said she could not ensure proper sanitizing levels were being met. Review of manufacturer instructions for Array Concentrated Ultimate Quaternary Sanitizer revealed to be effectively sanitized, items had to be immersed for at least 60 seconds in a sanitizing solution of the product, which measured with 200 parts per million with test papers. 3. Observation on 06/05/23 from 4:40 P.M. to 5:40 P.M. of the dinner service in the second floor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 10 of 11 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 365494 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapel Hill Community 12200 Strausser St NW Canal Fulton, OH 44614 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 servery with DD #701 revealed while taking the food temperatures of the items in the steam table, DE #419 had taken the cover off of the thermometer and placed the thermometer probe in the turkey, then in the beets, then in the mashed potatoes and then in the gravy. After taking the temperature of the gravy, DE #419 was observed taking an alcohol swab and wiping the gravy residue off the thermometer probe. DE #419 then took the temperature of the ground turkey and then the grilled cheese. DE #419 was observed wiping the thermometer probe with an alcohol swab prior to putting the thermometer away. Interview at the time of observation with DE #419 revealed he only wiped the thermometer probe with an alcohol swab prior to putting it away unless he needed to clean some residue off the probe. Interview with DD #701 during the observation revealed the thermometer probe should have been wiped with an alcohol between different items to prevent cross contamination. According to Servsafe Manager. 7th ed., National Restaurant Association Education Foundation, 2018, thermometers must be sanitized before and after using to prevent cross contamination (page 4.9). This deficiency was a result of incidental findings investigated under Complaint Number OH00143294. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 11 of 11