Inspection·December 15, 2022

F 0812 Level of Harm - Potential for minimal 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, interview and policy review the facility failed to maintain a record of meal substitutions that were provided in place of the approved daily menu. This had the potential to affect all residents in the facility with the exception of one(Resident #76) who did not receive food from the kitchen. The facility census was 81. Findings include: Review of the daily dinner menu for 12/14/22 revealed a meal listing of tomato basil soup, chicken salad sandwich on wheat, cucumber and onion salad, and poke cake. A substitution of a cheeseburger, french fries, green beans, and a brownie was made prior to serving the dinner meal. Interview with the Registered Dietician #4000 on 12/14/22 at 4:45 P.M. verified she was unable to provide a meal substitution log for the last three months, which included any substitutions made. Review of the facility policy regarding meal substitutions on 12/15/22 at 9:10 A.M. revealed an issue date of 11/2020. The policy states the menu substitution may be recorded on the menu or a separate log. Also, the registered dietician reviews menu substitutions and provides staff education as needed. 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: 365621 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 365621 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillsboro Post Acute 1141 Northview Drive Hillsboro, OH 45133 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)