Inspection·December 19, 2023

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, staff and resident interview, and review of the facility menu, the facility failed to follow weekly menus and have requested items available. This had the potential to affect 90 residents who receive their meals from the kitchen. The facility census was 94. Findings include: Observation on 12/18/23 at 11:42 A.M. of the lunch meal revealed Resident #67 was served a shredded chicken sandwich, hash browns, a piece of chocolate cake and two six-ounce glasses of orange colored juice. Resident #67 told State Tested Nursing Assistant (STNA) #95 he did not like chicken, and he wanted the alternate entree. STNA #95 stated the substitute was a bratwurst on a bun, and Resident #67 stated that would be fine. STNA #95 then returned to the dining room and told Resident #67 the kitchen did not have bratwurst available and that the only alternative available on 12/18/23 was a peanut butter and jelly sandwich. Observation on 12/18/23 at 11:45 A.M. revealed Resident #11 was served a grilled chicken sandwich, hash browns, a piece of chocolate cake and two six-ounce glasses of orange colored juice. Resident #11 tried to bite into the sandwich and stated it was too tough for her to bite. Resident #11 stated she could not eat it and she did not want the chicken sandwich, and no one had asked her what she wanted for lunch. STNA #95 told Resident #11 the only alternative available was a peanut butter and jelly sandwich. Resident #11 told STNA #95 she was diabetic and could not have a peanut butter and jelly sandwich because of the jelly and she would just have a banana instead. Resident #11 then requested a glass of cranberry juice, and STNA #95 told the resident the facility was out of cranberry juice. Observation on 12/18/23 at 11:50 A.M. of the lunch trays in the 2 East dining room revealed there was no milk on any of the meal trays. Interview 12/18/23 at 12:06 P.M. with Dietary Manager DM #16 confirmed the facility menu dated 12/18/23 revealed chicken sandwich was listed as the lunch entrée and the posted facility menu dated 12/18/23 revealed bratwurst on bun was listed as the lunch entrée. DM #16 confirmed the facility did not have sufficient quantities of chicken or bratwurst to serve the entire facility, so the cook made what he had of both items. DM #16 further confirmed the facility menu and the posted menu did not match and the only alternate menu item available was peanut butter and jelly sandwich. Interview on 12/18/23 at 12:16 P.M. with Resident #11 confirmed the facility kitchen was frequently out of items posted on the menu. Resident #11 confirmed today staff told her the only alternate menu item available was a peanut butter and jelly sandwich and they had no cranberry juice in the (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 2 Event ID: 365597 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 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)