F 0802
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition
service.
Based on observation, dietary staffing and schedule review and staff interview, the facility failed to employ
and maintain sufficient staffing in the kitchen to ensure resident meal service was provided as planned and
without potential interruption. This had the potential to affect all 29 residents residing in the facility.
Findings include:
Review of the facility meal schedule revealed breakfast service was scheduled for 7:30 A.M. and 8:10 A.M.
and lunch service was scheduled for 11:10 A.M. and 12:10 P.M. The second time noted was to finish the
delivery of resident hall trays (for those residents who ate in their rooms)
Upon entrance to the kitchen, on 03/15/24 at 8:30 A.M. Dietary [NAME] #49, State Tested Nursing Assistant
(STNA), STNA #50 and STNA #45 were observed in the kitchen preparing the residents morning meal. The
meal service was noted to be finishing at the time of the observation.
Interview with [NAME] #49 on 03/15/24 at 9:21 A.M. revealed the dietary aide scheduled to work in the
kitchen on this date had walked out after getting her paycheck this morning and did not work the rest of her
scheduled shift.
Interview with STNA #50 on 03/15/24 at 9:22 A.M. revealed she was working on this date and had a
resident care assignment, providing direct resident care but when she found out the kitchen was short
staffed, she volunteered to go to help in the kitchen because she had prior work experience in the kitchen.
Additional observation of the kitchen on 03/15/24 at 9:20 A.M. revealed Dietary [NAME] #49, STNA #50
and Dietary Manager (DM) #47 observed in the kitchen. STNA #45 went home after breakfast was served.
On 03/15/24 at 9:20 A.M. interview with DM #47 revealed she was the DM from the corporation's sister
facility and she was assisting today and completing the food order for next weeks delivery. The DM revealed
she had come to the building on this date to make sure food was ordered for next week as the food order
was due on Friday (03/15/24).
Observation of the lunch meal on 03/15/24 at 11:45 A.M. revealed the first cart was 35 minutes late.
Interview with kitchen staff at that time revealed the meal was running behind as it was only Dietary
[NAME] #49's third day of work and STNA #50 was just filling in in the kitchen.
(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:
366273
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
366273
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/18/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Enclave at Cambridge
8420 Georgetown Road
Cambridge, OH 43725
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 0802
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
On 03/15/24 at 12:30 P.M. telephone interview with the previous facility dietary manager (DM) revealed she
had recently (on 03/14/24) resigned her position in the facility. The DM stated she quit because she had
worked 45-60 days straight, (payroll) checks were no good and the company was going under. The DM
voiced concerns she was losing employees in the dietary department (had recently had her cook walk out)
and there were open shifts. She stated she physically was not able to cover (the open shifts) which was
leaving residents at risk. The DM revealed the rest of her staff that were still currently working were ready to
leave. The DM indicated based on the issues that were occurring she was not sure if meals would be
prepared or prepared on time.
Review of an All Staff listing with title document, provided by the facility on 03/15/24 revealed the staff
listing included four total dietary employees. This list did not match the dietary staffing schedule which
included seven staff names. The previous DM's name was not included on either the All Staff listing or the
dietary staffing schedule.
Review of the dietary staffing schedule, dated 03/15/24 through 03/24/24 revealed the schedule for these
dates included multiple scheduled shift times with no employee assigned to work during the time period.
For example, the schedule for 03/15/24 noted a dietary aide scheduled to start at 5:30 A.M. This dietary
aide was the aide who walked out on this date after receiving her paycheck and did not work the shift. The
schedule reflected three dietary staff shifts scheduled to start at 6:30 A.M. However, two of the shifts
appeared to be associated with vacant positions (as there was no staff name associated with them) and
only one of the shifts had a name, Dietary [NAME] #49. The schedule reflected two dietary employee shifts
to begin at 12:30 P.M. However, only one of the two shifts included a staff name. The second 12:30 P.M.
shift appeared to be for a vacant position.
Interview with the Director of Nursing (DON) on 03/15/24 at 1:15 P.M. verified the dietary aide who was
scheduled to work this morning with Dietary [NAME] #49, received her paycheck and walked out at that
time, leaving only the dietary cook to work in the kitchen. Due to the lack of dietary staff at that time, two
STNAs, one who was working the floor and one who came in to pick up her paycheck went to the kitchen to
assist with morning meal service.
This deficiency represents non-compliance investigated under Complaint Number OH00152028.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366273
If continuation sheet
Page 2 of 2
