Health inspection·December 29, 2023

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, staff interview, review of the facility kitchen cleaning schedule checklist, and review of the facility policy, the facility failed to maintain a clean and sanitary kitchen environment. This had the potential to affect 47 residents in the facility. Resident #8 received no food by mouth and thus no food from the kitchen. The facility census was 48. Findings include: Observation on 12/29/23 at 7:22 A.M. of the facility kitchen found the three-sink dishwashing system was not in use. Food debris and a wet towel with brown areas and brown specks was found under it. In addition, a wet area with three or four wet towels and steam table tray was observed on the floor under a steam oven. Interview on 12/29/23 at 7:25 A.M. with Dietary Manager (DM) #157 verified there was a wet soiled towel under the dishwashing sink and wet towels and tray under the steam oven. DM #157 reported there had been a drain leak under the sink so the towel was there to absorb the water. DM #157 reported the drain leak had been repaired but they had not removed the towel. DM #157 also verified there was some sort of leak under the steam oven. The towels and steam table tray were placed on the floor to absorb and catch the water. DM #157 reported they were not sure where the water was coming from but maintenance was aware and was trying to figure out where it was coming from. DM #157 reported she had started two months ago and was trying to get things in order. DM #157 reported the towels under the steam oven were changed every three to four days, but she was not aware of when the towel under the sink was last changed. Observation on 12/29/23 at 7:28 A.M. found built up food down the side of the gas grill stove top. The build up was much more than the eggs that were being cooked at the time. Interview on 12/29/23 at 7:30 A.M. with DM #157 verified the side of the grill and floors needed to be cleaned and had not been. DM #157 reported there were cleaning sheets posted for the cooks and dietary aides on all shifts but the tasks were not being completed. Observation on 12/29/23 at 7:31 A.M. of the walk-in cooler found debris, food pieces, and spilled liquids on the floor and under the shelves. A yellow substance, which appeared to have been a liquid, was dried and crusted to the floor. Observation on 12/29/23 at 7:33 A.M. of the walk-in freezer found debris and food pieces including frozen carrots and frozen French fries on the floor. (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: 365936 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 365936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Retirement Community of Lima Inc 2440 Baton Rouge Avenue Lima, OH 45805 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)