Health inspection·December 24, 2024

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 review of the facility policy, the facility failed to ensure food was stored in a safe and sanitary manner. This had the potential to affect all 57 residents in the facility. The census was 57. Findings include: 1. Observation on 12/24/24 at 8:15 A.M. in House #4 revealed a refrigerator with an opened and undated carton of broccoli soup, an opened and undated carton of potato soup, and a plastic reusable bag of food without a label or date. Further observation of a second refrigerator revealed what appeared to be several paper towels lying flat underneath the bottom drawer with a pinkish/red tint to them. Interview and observation on 12/24/24 at approximately 8:20 A.M. with Certified Nurse Aide (CNA) #101 confirmed the food items were opened, unlabeled, and undated. CNA #101 further confirmed the item under the bottom drawer of the refrigerator appeared to be paper towels and were pink/red in color. 2. Observation on 12/24/24 at 8:30 A.M. in House #2 revealed a refrigerator in the kitchen area with an opened and undated container of commercial macaroni salad with a puffed-up lid, an opened container of chicken tortilla soup dated 12/08/24, a container of cream cheese with a green substance growing on it, and a gallon milk container with an expiration date of 12/07/24. Continued observation of the refrigerator in the pantry of House #2 revealed a large reusable container of food without a label or date, and a black plastic container (similar to a restaurant take-home container) without a label or date. Additionally, the bottom drawer of the refrigerator had a dried substance that was pink in color. Interview and observation on 12/24/24 at 8:36 A.M. with CNA #102 confirmed the refrigerated items were unlabeled and expired, and further confirmed the dried substance in the bottom drawer appeared to have possibly been dried blood from leaking meat. 3. Observation and interview on 12/24/24 at 8:55 A.M. with CNA #103 in House #5 revealed a refrigerator in the kitchen area with an opened and undated bottle of apple juice, an opened container of sliced roast beef lunch meat with a tear in the seal and with a best if used by date of 09/24/24, a re-sealable bag containing food without a label or date, and a large undated metal bowl covered with aluminum foil containing chocolate pudding. Further observation of a refrigerator in the pantry area revealed a dried pink substance in the bottom drawer with a container of grapes, and an undated and opened container of apple juice. CNA #103 stated she just opened the apple juice in the first Page 1 of 4 366361 366361 12/24/2024 Otterbein Monclova 5069 Otterbein Way Monclova, OH 43542

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many refrigerator for breakfast and confirmed it was undated. CNA #103 further confirmed the additional undated and expired items in both refrigerators. 4. Observation and interview on 12/24/24 at 9:15 A.M. with CNA #104 in House #1 revealed a refrigerator in the kitchen area containing a sipper cup containing an off-white liquid. The sipper cup was unlabeled. Further observation and interview confirmed an opened and undated container of potato soup, a bowl of ground meat covered in plastic wrap without a label or date, and an opened container of commercial potato salad dated 12/08/24. CNA #104 stated she believe the sipper cup contained a nutrition supplement and confirmed it was undated and unlabeled. 5. Observation and interview on 12/24/24 at 9:49 A.M. with Life Enrichment Coordinator (LEC) #302 in House #3 confirmed the refrigerator in the kitchen area contained apple juice dated 11/01/24, and contained an opened and undated container of chicken broth. Further interview and observation with LEC #302 confirmed the refrigerator in the pantry area contained actual liquid at the bottom of the bottom drawer along with a wrapped ham. LEC #302 further confirmed the pantry contained a plastic tub of flour that was open to air, a scoop inside a container of oatmeal, and a bag of hamburger buns was open to air. Interview on 12/24/24 at 11:38 A.M. with Dietetic Technician (DT) #303 revealed each food item should have a delivery date and an opened date. Additionally, leftover food should be thrown out after four days and opened packaged food should be thrown out after four to seven days. Interview on 12/24/24 at approximately 3:00 P.M. with the Administrator revealed all 57 residents in the facility received food from the kitchen. Review of the policy titled, Food Storage Policy & Procedure, revised 05/2013, revealed bulk foods, such as flour, may be stored in a clean, covered container. Further review revealed prepared food should be should be covered, labeled and dated and should be used within four to seven days after the food was prepared. This deficiency represents non-compliance investigated under Complaint Number OH00160297. 366361 Page 2 of 4 366361 12/24/2024 Otterbein Monclova 5069 Otterbein Way Monclova, OH 43542

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and staff interview, the facility failed to maintain a clean and sanitary environment. This had the potential to affect all residents except 12 (#13, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, and #68) residents residing in House #5. The facility census was 57. Findings include: 1. Observation and interview on 12/24/24 at 1:36 P.M. with Maintenance Director (MD) #301 in House #1 revealed a kitchen cabinet under the sink. Further observation revealed the floor of the cabinet was collapsed and the veneer was separated from the particle board on the floor of the cabinet. The cabinet measured approximately three feet and 10 inches wide. MD #301 confirmed the back wall of the cabinet was modified to allow for plumbing and therefore the back wall did not touch the base or side walls of the cabinet. MD #301 confirmed approximately three inches of drywall were visible between the cabinet floor and the bottom of the back wall. MD #301 confirmed a black and dark brown substance was visible on the drywall across the three feet and 10 inch width of the cabinet. In some areas the substance fully coated the drywall and no white of the drywall was visible. In other areas the black and dark brown substance appeared spotted. The black and dark brown substance appeared flat to the wall and did not appear to be raised. There was a musty odor which came from the cabinet. MD #301 stated he believed the musty odor came from the collapsed base of the cabinet and stated he believed the base collapsed due to excessive weight, although MD #301 further confirmed the veneer was separated from the particle board. The cabinet contained two plungers and a bottle of dish soap. 2. Observation and interview on 12/24/24 at 2:08 P.M. with MD #301 in House #4 confirmed the cabinet under the kitchen sink was built to reveal drywall between the base and the back of the cabinet spanning the width of the cabinet and was approximately two inches high. Further observation revealed a light brown substance on the drywall covering approximately six inches wide and one inch high. Observed on the light brown substance were white, black, and gray pinpoint-sized spots. MD #301 peeled the brown off the wall, revealing white drywall beneath. MD #301 stated the brown color was the drywall discolored and peeling. 3. Observation and interview on 12/24/24 at 2:15 P.M. with MD #301 in House #3 confirmed the cabinet under the kitchen sink was built to reveal drywall between the base and the back of the cabinet spanning the width of the cabinet and was approximately two inches high. Further observation revealed an area approximately 12 inches wide and two inches high with light brown discoloration on the drywall. On the light brown areas were grey and black pinpoint spots. MD #301 confirmed the brown spotted areas and stated the drywall had been wet at some point but was dry during the current observation. Inside the cabinet were towels, scrub pads, and dishwasher soap. 4. Observation and interview on 12/24/24 at approximately 2:20 P.M. with MD #301 in House #2 confirmed the cabinet under the kitchen sink was built to reveal drywall between the base and the back of the cabinet spanning the width of the cabinet and was approximately two inches high. Further observation revealed an area approximately two feet wide and two inches high with light brown discoloration on the drywall. On the light brown areas were gray and black pinpoint spots. MD #301 confirmed the brown spotted areas on the drywall. MD #301 further confirmed pieces of drywall, approximately one to two inches in diameter, were at the back of the cabinet. The cabinet contained several bottles of dishwashing liquid. 366361 Page 3 of 4 366361 12/24/2024 Otterbein Monclova 5069 Otterbein Way Monclova, OH 43542

F 0921 This deficiency represents non-compliance investigated under Complaint Number OH00160297. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 366361 Page 4 of 4