Health inspection·June 2, 2022

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, and staff interviews, the facility failed to ensure residents were provided with adaptive equipment for drinking to maintain independence. This affected two (Resident's #18 and #66) of two residents (Resident's #18 and #66) who received adaptive equipment for drinking. The facility census was 54. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #66 revealed an admission date of 10/05/20 with diagnoses including but not limited to diabetes mellitus, hypertension, hemiplegia, spastic hemiplegic cerebral palsy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/07/22, revealed Resident #66 had moderate impaired cognition and independent with set up only for eating. Review of the physician's orders for May 2022 revealed a diet order for Low Concentrated Sweets diet, regular texture with thin consistency liquids. Resident #66 was also ordered Eating with set up, all food in individual bowls, foam built up utensils and foam cups with lids & straws. Review of the diet ticket for Resident #66 revealed Resident #66 was to receive two-handled cup with two lids, all food in bowls, built -up utensils and straws. Observation of lunch meal tray line on 06/01/22 at 12:02 P.M. revealed Resident #66 was supposed to get a two-handle cup with a lid but there were no lids available for the two-handled cups. This was verified by Diet Aide (DA) #517 at time of observation. Interview and observation on 06/01/22 1:30 P.M. with Resident #66 revealed he was in bed eating lunch and drinking a cold beverage from a two handled cup with no lid and no straw. Resident #66 reported he was unable to drink his beverage without a lid and straw because he would spill it on himself. 2. Review of the medical record for Resident #18 revealed an admission date of 04/21/21 with diagnoses including but not limited to wedge compression fracture of unspecified lumbar vertebra and heart disease. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 03/11/22, revealed Resident #18 had intact cognition and was independent with set up only for eating. Review of the physician's orders for May 2022 revealed orders for a regular diet, regular texture, and thin consistency liquids. Resident #18 was also ordered foam built up utensils at all meals with two handled cups (no lids). Observation of lunch meal tray line on 06/01/22 at 12:02 P.M. revealed Resident #18 was supposed to get a two-handle cup and got a regular coffee cup. Diet Aide #517 verified this finding at time of observation. Review of the facility policy dated 04/03/22 titled, Adaptive (Assistive) Eating Devices Policy revealed adaptive assistive eating devices were provided per physician's order or as needed. Interview on 06/01/22 at 3:03 P.M. with Registered Dietitian #571 revealed she had been employed at the facility for six weeks and did tray audits once a month. She had not in-serviced dietary staff on adaptive equipment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366127 If continuation sheet Page 2 of 3 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 366127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodlands Health and Rehab Center 6831 North Chestnut Street Ravenna, OH 44266 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 observations, interview and record review, the facility failed to ensure the kitchen was clean and sanitary. This had the potential to affect 72 residents who received meals from the kitchen, as one resident (#28) did not eat by mouth. The facility census was 73. Findings include: During the initial tour of the kitchen on 05/31/22 at 8:30 AM revealed the mixer used to make resident's food had dried food splatter on it. This was verified by Diet Aide #516 at 8:55 AM. A revisit to the kitchen on 06/01/22 at 10:30 A.M. revealed Dietary Manager (DM) #520 testing a sanitizer bucket containing a quaternary (quat) sanitizing solution. The bucket of quat sanitizer was used to sanitize food contact and preparation surfaces in the kitchen to prevent cross contamination of foods. At the time of testing the quat sanitizer it registered only 50 parts per million (ppm) indicating it was not within the proper range of 200ppm to 400ppm for a quat sanitizer. [NAME] # 519 was present and stated the sanitizer needed to be changed because she sanitized the food preparation surface after she was preparing raw chicken. [NAME] #519 revealed the sanitizer concentration was not getting checked during the day because she didn't know how to do it. DM #520 took the bucket, refilled with quat sanitizer, dipped a quat sanitizer test strip into the bucket and it read 50 ppm. DM #520 went to the three-compartment sink, came back with another bucket of sanitizer, dipped the test strip and the strip read 200 ppm of quat sanitizer. Review of the facility policy dated 06/01/18 titled, Sanitizer Bucket Policy revealed the temperature and strength of the sanitizing bucket shall be monitored and recorded following each meal. If there is a concern about the sanitizing quality due to inappropriate sanitizer strength that cannot be resolved by the employee, the cleaning of food contact surfaces shall be stopped and reported to the DM for corrective action. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366127 If continuation sheet Page 3 of 3