Health inspection·October 10, 2019

F 0755 Level of Harm - Minimal harm or potential for actual harm Review of Medscape drug information revealed Midodrine was a medication used for symptomatic orthostatic hypotension. Review of the facility's policy titled, Administering Oral Medications and dated October of 2010, revealed perform any pre-administration assessments and to review the physician's order. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366080 If continuation sheet Page 2 of 6 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 366080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chesterwood Village 8073 Tylersville Road West Chester, OH 45069 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of the planned menus, the facility failed to ensure the planned menu approved by a Registered Dietitian (RD) was followed regarding portion sizes, and preparation of all menus items specified for mechanically soft diets. This directly affected nine (#2, #18, #31, #343, #34, #304, #71, #24, #13) residents on mechanical soft diets, and had the potential to affect all residents of the facility with the exception of residents #81 and #65 who received all food and fluids via gastrostomy tube. The facility census was 92. Findings include: Food preparation and service was observed on 10/08/19 for the evening meal beginning at 3:57 P.M., in the central kitchen and in each of the two dining room serverys; Birch and [NAME]. The planned menu included turkey cacciatore, egg noodles, crumb topped Brussels sprouts, biscuit, gingersnap cookie, and assorted beverages. The alternative entrée menu items included salmon burger and pickled Asian slaw. Review of the planned menu for the 10/08/19 evening meal, approved by a Registered Dietician (RD), revealed that residents with orders for a mechanical soft diet were to receive soft chopped Brussels sprouts instead of the regular whole crumbed topped Brussels sprouts. In addition, review of the planned menu, approved by a RD, revealed that residents on a regular diet were to receive a 6 ounce ladle/spoodle of the turkey cacciatore. The Birch dining room servery was observed on 10/08/19 at 5:00 P.M., with Corporate Food Service Director (FSD) #116. The steam table was set for service, and Diet Aide (DA) #143 begun plating food. Observations of the menu items and portions sizes of the food being served revealed that DA #143 was using a #10 scoop, the equivalent of 3.2 ounces, to serve residents the turkey cacciatore instead of the planned 6 ounce portion. In addition, there were no soft chopped Brussels sprouts prepared for service to residents with orders for a mechanical soft diet. FSD #116 affirmed at the time of the observation the portion size being served to residents was not consistent with the planned menu, and no soft chopped Brussels sprouts had been prepared. He confirmed the whole Brussels sprouts were not appropriate to serve to residents on a mechanical soft diet. FSD #114 who was also present was asked if any soft chopped Brussels sprouts were prepared for any residents on mechanical soft diets, he communicated that no chopped Brussels sprouts had been prepared. At 5:15 P.M., FSD #114 then removed several portions of the whole Brussels sprouts into a pan to return to the kitchen to chop. The [NAME] dining room servery was observed on 10/08/19 at 5:27 P.M., with Corporate FSD #116. The steam table was set for service, and DA #139 begun plating food. Observations of the menu items and portions sizes of the food being served revealed that DA #139 was using an 8 ounce serving of turkey cacciatore versus the planned 6 ounce portion. In addition, there were no soft chopped Brussels sprouts prepared for service to residents with orders for a mechanically soft diet. FSD #116 affirmed at the time of the observation the portion size being served to residents was not consistent with the planned menu, and no soft chopped Brussels sprouts had been prepared. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366080 If continuation sheet Page 3 of 6 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 366080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chesterwood Village 8073 Tylersville Road West Chester, OH 45069 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of facility policy, the facility failed to ensure that food was prepared and served in accordance with professional standards for food safety to prevent the food borne illness. This had the potential to affect five Residents (#5, #35, #65, #14, #21) with physician orders for a pureed diet, as well as all the residents of the facility except for Residents #81 and #65 who received all food and fluids via gastrostomy tube. The facility census was 92. Findings include: Food preparation and service was observed on 10/08/19 for the evening meal from 3:57 P.M. through 5:30 P.M. Observations were made in the central kitchen and in each of the two-dining room serverys; Birch and [NAME]. The planned menu included turkey cacciatore, egg noodles, crumb topped brussels sprouts, biscuit, gingersnap cookie, and assorted beverages. The alternative entrée menu items included salmon burger and pickled asian slaw. Observation of the central kitchen with Chef #125 and [NAME] #124 on 10/08/19 at 3:57 P.M. revealed that all menu items for the evening meal were prepared and were either in the central kitchen steam table, or in the heated food holding cabinets for delivery to the dining room serverys. The temperatures of the hot food on the steam table were taken by Chef #125 at 4:00 P.M. and were found to be greater then 135 degrees Fahrenheit (F), and less than 160 F. He stated that service of the food on the steam table would begin until about 4:40 P.M. [NAME] #124 then stated he liked the hot food to be about 165 F or more, and that the food should be about that temperature by 5:00 P.M. after being heated up on the steam table for about an hour. Chef #125 was then asked to take the temperature of the food in the heated food holding cabinets. The food going to the [NAME] dining room servery, and the mechanically altered food going to the Birch dining room servery, was selected for temperature sampling. The temperature of the pureed turkey cacciatore was 123 F. The temperature of the chicken gumbo soup (a left over from the lunch time meal) was 125 F. [NAME] #124 who was present while taking the food temperatures stated that the temperature of the chicken gumbo soup was not at the right temperature as it came off the stove and he didn't actually heat it up. He verbalized the food in the heated cabinets would heat up to the right temperature by serving time. The temperature of the mechanical soft turkey cacciatore was 137 F. Chef #125 recognized and stated the temperature of the pureed turkey cacciatore and the chicken gumbo soup was below acceptable safe holding temperature and returned the food to the oven/steamer. He also commented the mechanically soft turkey cacciatore was marginally acceptable and also returned that menu item to the oven/steamer. On 10/08/19 the temperatures of the hot food in the steam table in the Birch dining room servery were taken by Corporate Food Service Director (FSD) #116 at 5:00 P.M. The temperature of the egg noodles was 117 F. The egg noodles were served at this temperature to residents. On 10/08/19 at 5:20 P.M. FSD #116 left the Birch servery and returned with a tureen of the chicken gumbo soup. FSD #116 then took the temperature of the gumbos soup which had previously been 125 F. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366080 If continuation sheet Page 4 of 6 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 366080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chesterwood Village 8073 Tylersville Road West Chester, OH 45069 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 - Some the temperature of the soup ranged from 159 F to 164 F after being stirred. FSD #116 stated the temperature of the soup needed to be at least 165 F before serving as it was a left over from the lunch time meal. FSD #116 left the servery and then returned with the soup which was then 173 F. FSD #116 was interviewed after the meal observation at 5:30 P.M. and the concerns with dietary staff using hot food holding equipment as a means for cooking or heating food that had not been initially cooked or heated to a safe temperature. He affirmed that the steam tables and heated food holding cabinets were not for cooking or re-heating food. The facility policy and procedure titled Food Temperatures was reviewed. The policy specified that hot foods shall not be cooked or reheated for service in a steamtable, crock pot, or similar equipment. The procedure specified that hot food was to be held at 135 F or greater throughout the service process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366080 If continuation sheet Page 5 of 6 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 366080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chesterwood Village 8073 Tylersville Road West Chester, OH 45069 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview and facility policy review the facility failed to ensure proper infection control with the use of glucose monitors. This affected one resident (Resident #84) and had the potential to affect two residents (Resident #84 and #345) on the 500 hall who received glucose monitoring. The facility census was 92. Residents Affected - Few Findings include: Observation on 10/08/19 at 8:05 A.M. of Resident #84's glucose monitoring provided by Licensed Practical Nurse (LPN) #243 revealed after the resident testing was completed, the nurse brought the glucometer back to the medication cart and placed the glucometer on the cart's surface with no protective barrier. LPN #243 opened the medication cart and removed alcohol preps and cleansed the glucometer with the alcohol prep. Interview on 10/08/19 at 8:10 A.M. with LPN #243 revealed after using the glucometer, she always cleanses the glucometer with alcohol preps. When asked about disinfecting wipe or bleach wipes, LPN #243 stated there were some disinfecting wipes in the nurse's medication room. The LPN locked the cart and returned with the disinfecting wipes and proceeded to clean the glucometer. Interview on 10/08/19 at 11:10 A.M. with the Director of Nursing (DON) revealed the facility's expectation was glucometers should be cleansed with disinfecting wipes. The DON stated each medication cart was stocked with individualized disinfecting wipes. The DON verified there were two only two residents (#84 and #345) who received glucose monitoring and resided on the 500 hall. Review of the undated policy titled, Cleaning and Disinfection of Glucose Testing Monitors revealed glucose monitors will be cleaned and disinfected by the use of appropriate disinfectant. Glucometer cleaning and disinfecting will be performed after each use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366080 If continuation sheet Page 6 of 6