Inspection·February 20, 2020

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 and policy review, the facility failed to ensure foods in the coolers and freezer were dated and stored in closed containers. The facility also failed to ensure the kitchen was clean. Additionally, the facility failed to appropriately discard items that were contaminated. This had the potential to affect all 46 residents residing in the facility whose meals were prepared in the kitchen. The facility census was 46. Findings included: 1. The initial tour of the kitchen on 02/18/20 at 10:19 A.M. revealed the following areas of concern: • Floor under deep fryer had a heavy black buildup of unknown material. • The reach in cooler #2 had four hot dogs in plastic bag and a log of sliced cheese which was open and undated. • The reach in freezer #1 had four, three-gallon containers of ice cream and a bag of french fries which was opened and undated. Ice cream containers were not sealed properly with lids exposing contents to air. • Walk in freezer had an opened undated bag of french fries. There was also a plastic mat on the floor with an open weave, in between multiple weaves was a buildup of unidentified multicolored material. • Dry food storage had an opened and undated bag of pinto beans. Interview with Interim General Manager #288 verified all areas of concern on 02/18/20 at 11:30 A.M. (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: 366232 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 366232 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westover Retirement Community 855 Stahlheber Road Hamilton, OH 45013 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)