Inspection·October 12, 2023

F 0804 She stated there were no more visibly moldy sandwiches. Level of Harm - Minimal harm or potential for actual harm Review of the signed witness statement dated 09/18/23 revealed Dietary #102 had made the sandwiches and wraps after lunch and at the time of making the sandwiches he saw no visible mold until the nursing assistant came and showed a moldy sandwich to him. He stated he stopped the tray line and made turkey and cheese sandwiches and the dietary aide pulled all the meal carts back into the kitchen and they changed out the sandwiches on the trays. Residents Affected - Few On 10/11/23 at 10:10 A.M. an interview they Resident #24 revealed he stated he received a ham sandwich that was moldy. He stated it was dark in his room, he started eating the sandwich and it had tasted funny so he took a closer look and that was when he saw the mold on it. The aide told him they were picking up all the ham sandwiches because they had mold on them. He stated he got sick and threw up once outside and once in his toilet after eating the sandwich. On 10/11/23 at 11:10 A.M. an interview with Licensed Practical Nurse #100 revealed about three weeks ago a nursing assistant brought a sandwich to her that had visible moldy green lunch meat in it. She stated she was not sure what room she got it from. On 10/11/23 at 11:50 A.M. an interview with Food Service Manager (FSM) #101 revealed she had never had any complaints of spoilage of food except about three weeks ago it was brought to their attention during the evening meal a resident stated his ham sandwich did not taste right. She stated they had just sent the first cart out so Dietary #102 made the decision to not serve the ham and replace the sandwiches with turkey. She stated all the ham sandwiches were retrieved and thrown away. She stated they never tried the ham so she does not know if it was bad or not and Resident #24 had eaten his so they were not able to see it. On 10/11/23 at 4:10 P.M. an interview with State Tested Nursing Assistant (STNA) #103 revealed she had been working the evening the residents received moldy ham and cheese sandwiches. She stated there were several residents who received them but Resident #24 was the only one who ate the sandwich before realizing it had been moldy and he was very upset. He went to the kitchen and started yelling at the kitchen staff. She stated they did take all the sandwiches back to the kitchen and threw them out and gave the resident a non-moldy sandwich. She stated she took a picture of one of the sandwiches she seen with the mold. On 10/12/23 at 12:20 P.M. an interview with STNA #107 revealed she had been working on the 100-hall and she got her meal trays first. She took the trays to Resident #19 and Resident #37 in their room. She stated Resident #37 got a bologna sandwich but Resident #19 got the ham sandwich. She stated Resident #19 liked her sandwiches cut up so she began to cut it up and noticed it had mold on it. She told the resident she could not eat it because it was moldy and took the tray away for her. She stated she went back out to the meal cart and looked at all the residents' sandwiches and all the ones with ham on them were moldy. She stated she told everyone working to check their sandwiches and took the cart to the kitchen. She stated she told Dietary #102 and he took the sandwich from her, ripped the moldy part off and said it was fine. She stated she told him she was not feeding those sandwiches to the residents. She stated he did not do anything and sent out the 200-hall meal cart with the same sandwiches. She stated the nursing assistant working on that hall passed out the trays even after she told him they had mold on them. She stated she called the ED to tell her of the situation. She added Resident #24 had already eaten his sandwich by the time they went around to pick up the sandwiches to switch them out. She stated Resident #24 was furious. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366267 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 366267 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Mayfield Village, Inc 290 North Commons Blvd Mayfield Village, OH 44143 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 0804 Level of Harm - Minimal harm or potential for actual harm On 10/12/23 at 12:40 P.M. an interview with Resident #19 revealed last month she received a moldy ham sandwich from the kitchen. She stated she had seen the mold on it. She stated the aide took the sandwich before she could eat it. This deficiency represents non-compliance investigated under Complaint Number OH00146475. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366267 If continuation sheet Page 3 of 3