Inspection·March 14, 2024

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 observations, staff interview, and review of the menu and whiteboard, the facility failed to follow the prepared menus and failed to ensure the changes to the menu were approved by a qualified clinical nutrition professional for nutritional adequacy. This affected four of four meals reviewed during the survey. This had the potential to affect the 22 residents who received meals from the kitchen. The facility census was 24. Finding include: Review of the facility's menu for Fall and Winter 2023 to 2024 revealed they menu was signed but it was unknown who the person was because it was not the Registered Dietitian (RD) for the facility. The lunch menu for Wednesday 03/13/24 was chicken barbeque, macaroni and cheese, baked beans, and a peanut butter bar. The white board (located in the hallway near the residents' rooms) revealed the residents would be receiving hamburger gravy, mashed potatoes, green beans, and pudding. The dinner menu for Wednesday 03/13/24 was taco salad, refried bean, lettuce and tomato, crackers, and cream pie. The white board revealed the residents were to receive barbeque chicken nuggets, baked beans, mixed vegetables, and fruit. The lunch menu for Thursday 03/14/24 was baked ziti, garlic bread, green beans, and fruit salad. The white board revealed the residents were to receive breaded chicken with gravy, macaroni and cheese, bean and carrot medley, and apple pie. The dinner menu for Thursday 03/14/24 was pork riblet, creamed corn vegetable medley, dinner roll, and sherbert. The white board revealed the residents would receive stuffed pepper soup, grilled cheese, and fruit. Observations on 03/13/24 and 03/14/24 at lunch and dinner revealed the residents were served the meals which were noted on the whiteboard and not what listed in the menu for these days. Interview with [NAME] #600 on 03/13/24 at 12:01 P.M. verified he did switch the lunch and dinner menu for this day. [NAME] #600 was unsure if the RD was aware of changes made to the menu, because he does not notify anyone of the changes. [NAME] #600 stated he does not do the ordering and it was the dietary manager who does the ordering. When he makes changes to the menu, he writes it on the whiteboard first thing in the morning for the residents to see and if they may want a substitution. (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: 366002 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 366002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestline Rehabilitation and Nursing Center 327 West Main Street Crestline, OH 44827 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)