Health inspection·March 6, 2024

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included type two diabetes, hypertension, and palliative care. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #30 was on a therapeutic and mechanically altered diet. Review of the physician orders dated 07/17/23 revealed Resident #30 was ordered a carbohydrate controlled, mechanical soft diet with honey thickened liquids. Observation of the lunch meal service on 03/06/24 at 12:08 P.M. revealed Resident #30 was provided a Philly cheese steak sandwich, cooked cauliflower, peaches, juice, water, and strawberry ice cream. Interview with State Tested Nursing Assistant (STNA) #185 on 03/06/24 at 12:10 P.M. confirmed Resident #30 was on a carbohydrate controlled, mechanical soft diet with honey thickened liquids. STNA #185 confirmed the food consistencies provided were correct and she was thickening the liquids to honey thickness. STNA #185 verified Resident #30 had strawberry ice cream provided on his lunch meal tray. Interview with Dietary Manager (DM) #105 on 03/06/24 at 12:15 P.M. and observation of the diet spreadsheet for a carbohydrate controlled diet. DM #105 verified Resident #30 should not have been provided the ice cream as it was not included on the diet spreadsheet for a carbohydrate controlled diet for the lunch meal on 03/06/24. DM #105 stated the ice cream was included on his tray in error. DM #105 was observed to remove the ice cream from Resident #30's tray while he was eating his meal. 3. Review of Resident #80's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included diastolic heart failure, hyperkalemia, atrial fibrillation, morbid obesity, and hypertensive heart disease. Review of the physician orders revealed Resident #80 was ordered a cardiac diet with regular texture and thin liquids on 02/16/24. Observation of meal tray pass for the lunch meal on 03/06/24 at 12:18 P.M., Resident #80's meal tray was observed with Registered Nurse (RN) #255. RN #255 confirmed Resident #80 had foil wrapped sandwich, cooked cauliflower, peaches, and strawberry ice cream as the food items provided on the tray. Review of the diet spreadsheet menu for the cardiac diet for the lunch meal on 03/06/24 with RN #255 at the time of the observation revealed the cardiac diet did not include having ice cream. RN #255 confirmed, based on the diet spreadsheet, the ice cream should not have been provided to a resident on a cardiac diet and the RN removed the ice cream from Resident #80's meal tray. Review of the resident council meeting minutes for 12/26/23 revealed the residents would like to have more diabetic food options, and one (unnamed) resident stated she continues to receive food she was allergic to at breakfast (eggs). The minutes dated 02/29/24 revealed several residents stated they do not get what they order daily and several residents question why dietary staff was not working with the residents. Interview with the Administrator on 03/06/24 at 4:00 P.M. regarding the resident councils' dietary concerns revealed no follow up had occurred as the DM was unaware of having a mailbox at the facility. The Administrator stated the resident council meeting minutes were found to be in the DM's mailbox when the Administrator showed the DM where his mailbox was located at the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366142 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 366142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mill Run Care Center 3399 Mill Run Drive Hilliard, OH 43026 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the education titled Diet Basics revealed all diets are ordered by the doctor and are considered as important as medications. Diet drive all production and meals processes. Diets information is communicated to staff through diet tickets, bistro menus, diet spreadsheets, diet manuals, tally sheets, diet lists, etc. Diet spread sheets indicates what each diet should receive based on the diet order and nutrition guidelines and are written and signed off by the corporate dietitian. Based on recent information related to the diet and the company diet manual, they should be followed. Misinformation or information which needs to be updated should be communicated to the manager. Changes to portions should be approved by manager and noted on the diet spreadsheets. Review of the facility policy titled Accuracy of Tray Line, dated 03/01/11 last revised 11/01/22, revealed it is the center's policy to provide meals that are accurate, follow physician orders, and patient/resident requests. The purpose of the procedure is to assure each patient/resident receives what he/she ordered for each meal and follows the physician's order. It is the responsibility of the Dietary Manager to ensure each meal served is accurate. The Administrator is responsible for the oversight of this operation. Problems with tray accuracy will be resolved immediately. Ongoing problems are brought to the attention of the dietary manager. This deficiency represents non-compliance investigated under Complaint Number OH00151152. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366142 If continuation sheet Page 3 of 3