Health inspection·November 17, 2022

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #18's Pre-admission Screening and Resident Review (PASARR) documents were accurate related to the resident's condition and diagnoses. This affected one resident (#18) of one resident reviewed for PASARR. Findings Include: Record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including hypertensive heart and chronic kidney disease, heart failure, atrial fibrillation, end stage renal disease, type II diabetes, orthostatic hypotension, atherosclerotic heart disease, major depressive disorder, dysphagia, chronic respiratory failure, delusional disorder, peripheral vascular disease, generalized anxiety disorder, hyperlipidemia, iron deficiency, gout, and insomnia. Review of Resident #18 PASARR document, dated 12/16/19 revealed under Section D, it indicated the resident had no mental health diagnoses. However, review of the resident's diagnoses list, the resident had the following diagnoses that should have been indicated on the PASARR document: major depressive disorder (dated 11/21/19). Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/10/22 revealed the resident was cognitively intact. On 11/17/22 at 10:09 A.M. interview with Licensed Practical Nurse (LPN) #135 revealed the facility would complete a PASARR/update a PASARR document after 20 days of an initial stay after a resident's admission from the hospital or a resident had left to go to the hospital, and was not back in the facility for 72 hours. LPN #135 revealed the facility did not have a mechanism/procedure to inform her of updated/added mental health diagnoses while resident was in the facility. She confirmed Resident #18 had mental health diagnoses that were not included in the PASARR documentation submitted for review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365742 If continuation sheet Page 2 of 5 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 365742 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE National Church Residences Bristol Village 444 Cherry St Waverly, OH 45690 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 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a new Pre-admission Screening and Resident Review (PASARR) was competed for Resident #18 following changes to the resident's mental health diagnoses. This affected one resident (#18) of one resident reviewed for PASARR. Findings Include: Record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including hypertensive heart and chronic kidney disease, heart failure, atrial fibrillation, end stage renal disease, type II diabetes, orthostatic hypotension, atherosclerotic heart disease, major depressive disorder, dysphagia, chronic respiratory failure, delusional disorder, peripheral vascular disease, generalized anxiety disorder, hyperlipidemia, iron deficiency, gout, and insomnia. Review of Resident #18 PASARR document, dated 12/16/19 revealed under Section D, it indicated the resident had no mental health diagnoses. However, review of the resident's diagnoses list, the resident had the following diagnoses that should have been indicated/updated on the PASARR document: major depressive disorder (dated 11/21/19), delusional disorders (dated 12/02/20) and generalized anxiety disorder (added 06/09/20). Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/10/22 revealed the resident was cognitively intact. On 11/17/22 at 10:09 A.M. interview with Licensed Practical Nurse (LPN) #135 revealed the facility would complete a PASARR/update a PASARR document after 20 days of an initial stay after a resident's admission from the hospital or a resident had left to go to the hospital, and was not back in the facility for 72 hours. LPN #135 revealed the facility did not have a mechanism/procedure to inform her of updated/added mental health diagnoses while resident was in the facility. She confirmed Resident #18 had mental health diagnoses that were not included in the PASARR documentation submitted for review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365742 If continuation sheet Page 3 of 5 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 365742 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE National Church Residences Bristol Village 444 Cherry St Waverly, OH 45690 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, facility policy and procedure review and interview the facility failed to properly store, date (label), and prepare food to protect against contamination and/or spoilage. This had the potential to affect all 37 residents residing in the facility. Findings Include: 1. On 11/14/22 at 8:45 A.M. and 9:20 A.M. observation in the kitchen revealed three sealed/unopened packages of ham in a large plastic container in the walk in refrigerator. Two packages were thawed and cool to the refrigerator's temperature. One package still had frost/ice on the outside and was frozen to touch. Neither package had a date as to when it was delivered or when it was removed from the freezer to thaw for service. Also, there was one package of a block of cheese that was in a sealed plastic bag, due to the cheese being opened but not fully used. There was no date on the bag of the cheese as to when it was opened. Finally, there was a large metal pan of vegetable soup with no top and no date on the pan, inside the walk in freezer. Interview with Dietary Staff #201 on 11/14/22 at 8:50 A.M. confirmed the ham packages that were in the walk in refrigerator, were originally in the freezer. She confirmed staff typically take frozen items out of the freezer, and allow them to thaw in the refrigerator for three days, and then use them. She confirmed she does not know the exact date when the packages of ham were taken out, but confirmed that one package was still frozen and two were not. She stated she cooked the vegetable soup that morning, and put it in the freezer to cool, because it would be served for the residents to eat in a few days. She indicated there was no lid on the pan of vegetable soup, so it would cool/freeze faster. Interview with Director of Food Services #123 on 11/14/22 at 9:20 A.M. confirmed there was no date on the three packages of ham, block of cheese in the plastic bag, and vegetable soup that was in the freezer. She also confirmed there should be dates on all three items; when the vegetable soup was placed in the freezer, when the ham was removed from the freezer to the refrigerator, and when the cheese was first opened. She also confirmed the pan of vegetable soup should have had a lid on it. Review of facility Refrigerated Storage policy, dated January 2016 revealed perishable foods shall be stored in a manner that optimizes food safety and quality. All pre-dished items shall be covered to prevent off-flavoring, drying, or cross contamination while refrigerated. Food container covers shall be impervious and non-absorbent. Refrigerated items shall bear a label indicating product name and date (month, day, year) product was received, used or first opened. Review of Frozen Storage policy, dated January 2016 revealed all frozen products shall be labeled indicating product name and date of delivery (month, day, and year). Review of facility Thawing policy, dated January 2016 revealed all frozen foods shall be thawed in a manner that optimizes food safety and quality. The dietary manager or designee shall indicate products to be removed from the freezer for thawing. Food shall be thawed under refrigeration that maintains the food temperature at 41 degrees Fahrenheit or below. Food items shall be placed in a pan to collect any juices and shall be placed on the lowest refrigerated unit shelf to prevent cross contamination. Pan shall be checked frequently to prevent overflow. Food items shall be placed in separate pans for thawing (do not thaw chicken with beef or ham.) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365742 If continuation sheet Page 4 of 5 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 365742 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE National Church Residences Bristol Village 444 Cherry St Waverly, OH 45690 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. On 11/16/22 at 10:17 A.M., 10:21 A.M., and 10:25 A.M. Dietary Staff (DS) #201 was observed with a disposable glove on her right hand. DS #201 was observed to place pieces of pork into the blender with her gloved hand. After putting the pork in, she touched the blender, dirty counter top, metal pans, cloth towel, utensil, and blender lid. Then, she put more pork into another blender to make ground textured meat. She used the same gloved hand (did not change glove), to put more of the meal into the blender. After blending the meat to the proper texture, she opened the lid and put the same gloved hand on the inside of the blender to hold the blade intact while dumping the meat into a metal pan. After putting the metal pan of ground meat on the steam table, she took the pork gravy pan to the steam table to put it on the tray line as well. Prior to doing that, she wiped the sides of the gravy pan with the same gloved hand four times, and put the wiped gravy back into the gravy pan. Interview with Dietary Staff #201 on 11/16/22 at 10:26 A.M. confirmed she did not change her gloves throughout the entire preparation and storage process listed above. DS #201 revealed she does not change her gloves while she is working with the same food type (all pork products). Review of facility Disposable Gloves policy, dated October 2020 revealed disposable gloves shall be used for only one task and shall be discarded when damaged or soiled or when interruptions occur in operation. Gloved hands were considered a food contact surface that could become contaminated or soiled. Disposable gloves need to be changed between tasks and as often as hands need to be washed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365742 If continuation sheet Page 5 of 5