Inspection·December 28, 2023

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on review of the facility menu, observations, resident and staff interviews, review of recipes, the facility failed to provide nutritious and palatable meals to residents. This had the potential to affect 67 residents in the facility who received meals prepared in the kitchen. The census was 68. Residents Affected - Many Findings include: Review of the facility menu dated 12/28/23 revealed the breakfast meal included waffles, sausage, and oatmeal. Observation on 12/28/23 at 8:30 A.M. of the 400 Unit service line for breakfast revealed Dietary Aide (DA) #140 opened a plastic bag of thawed waffles which were sitting in a warmer tray. DA #140 placed a waffle onto a resident's plate. Interview on 12/27/23 at 8:30 A.M. of DA #140 confirmed the waffles came frozen and were steamed in their original packaging and then plated to serve to the residents. Observation of a test tray on 12/28/23 at 8:35 A.M. revealed the frozen waffle was light yellow in color with no toaster marks and was soft and wet. The sausage link was dark brown in color, hard, and difficult to cut. Interview on 12/28/23 at 8:35 A.M. with Dietary Manager (DM) #145 confirmed the waffle was soft and wet and the sausage link was hard and difficult to cut. Interviews on 12/28/23 from 9:10 A.M. to 9:20 A.M. with Residents #40, #41 and #42 confirmed the waffles were too soft to eat and had not been properly cooked. Interview on 12/28/23 at 9:00 A.M. with DM #145 confirmed the dietary staff did not follow the waffle recipe. Observations on 12/28/23 at 9:25 A.M. of Residents #40, #41, and #42 revealed the residents did not consume the waffles. Review of the facility recipe for buttered waffles undated revealed waffles should be kept frozen until ready to use and should be toasted in a toaster on low to medium setting and heated until hot and crispy. Alternatively, waffles could be prepared in a conventional oven pre-heated to 400 degrees Fahrenheit (F). Frozen waffles should be placed on a sheet pan in a single layer and baked uncovered for eight to 10 minutes until crispy. (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: 366400 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 366400 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beavercreek Health and Rehab 3854 Park Overlooke Drive Beavercreek, OH 45431 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)