Inspection·May 28, 2025

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 interviews, and review of facility policy, the facility failed to ensure staff had there hair contained in food preparation areas and failed to ensure food was stored properly. This had the potential to 98 out of 98 residents who receive their meals/food from the kitchen, the facility identified one resident (#30) that did not receive food from the kitchen. The census was 99. Findings include: Observations of the kitchen on 05/21/25 at 2:14 P.M. revealed Dietary Aide (DA) #150 preparing meals trays and DA #160 arranging drink cups and preparing drinks. Neither DA #150 or DA #160 had were wearing hairnets or had their hair contained. Interview with DA #150 on 05/21/25 at 2:19 P.M. confirmed she was not wearing a hairnet. DA #150 stated her hairnet must have fell off. Interview with Dietary Director (DD) #170 on 05/21/25 at 2:29 P.M. confirmed DA #150 and DA #170 were not wearing hairnets and did not have their hair contained in the food preparation area. DD #170 stated hairnets were required at all times in the kitchen. Further observation on 05/21/25 at 2:25 P.M. revealed an unlabeled and undated plastic container of apple pie filling and an open and undated package of cheese slices in the refrigerator. A box of hamburger patties, a plastic bag containing rolls, and a box containing a turkey were being stored directly on the floor of the freezer. Interview with DD #170 on 05/21/25 at 2:33 P.M. confirmed the above findings. DD #170 confirmed that food should be dated and labeled. DD #170 confirmed food items should not be stored directly on the floor of the freezer. During an interview on 05/28/25 at 1:43 P.M. the Director of Nursing (DON) identified Resident #30 as being nothing by mouth (NPO) and not receiving food from the kitchen. The DON stated all other 98 residents residing in the facility receive their meals/food from the kitchen. Review of the facility's policy titled, Food Storage dated 2021 revealed sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Food items will be stored on shelves, with heavier and bulkier items stored on lower shelves. Food should be stored a minimum of (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: 365821 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 365821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Walnut Creek Nursing Center 5070 Lamme Road Kettering, OH 45439 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)