Health inspection·December 27, 2018

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 observations, staff interview, and review of the manufacturer's recommendations/facility policy, the facility failed to ensure food was properly labeled and stored, and dishes were sanitized in a manner to prevent contamination. This had the potential to affect two (#107 and #108) of two residents who reside in the facility. Findings include: Observations on 12/26/18 at 8:52 A.M. with Food Service Director (FSD) #300, revealed the walk-in freezer contained multiple food items that were expired. The food were as follows: diced chicken (two packs) opened and repackaged in gallon size zip lock bags dated 08/12/18; corn beef wrapped in aluminum foil dated 05/08/18; pastrami (two packs) wrapped in aluminum foil dated 06/07/18; one unidentified food item wrapped in aluminum foil, unlabeled and undated; apple corn bread stuffing opened and repackaged in gallon size zip lock bags dated 01/24/18, ham wrapped in aluminum foil and undated; and one bag of frozen peas, opened and undated. In the reach in freezer there was an opened and undated package of English muffins, and toast was repacked in a zip lock bag dated 12/10/18. In the walk-in refrigerator there were multiple opened and repackaged containers including: chili sauce dated 12/11/18; two opened and repackaged containers of tomato paste dated 12/16/18; pesto sauce opened, repackaged and undated; ketchup opened and repackaged dated 12/15/18; and oyster sauce opened and repackaged dated 12/11/18. In the service area reach-in refrigerators there were three opened and undated packages of cheese. Interview with FSD #300 during the time of the observations, verified all the items noted above were opened and expired or undated. FSD #300 stated he needs to work on dating food. FSD #300 stated the facility practice was to discard opened food after seven days in the refrigerator. Regarding foods in the freezer, FSD #300 stated he discards foods after three or four months but was unsure of the facility policy for the length of time things can be stored in the freezer. FSD #300 further verified the frozen foods noted above should have been discarded. FSD #300 stated the items in the walk-in refrigerator should have been labeled with the manufacturer's expiration date. He also verified both Resident #107 and Resident #108, were served meals from the kitchen. Continued observations revealed the kitchen three-sink dishwashing system was in use. FSD #300 obtained a test strip to check the sanitizer. He dipped the strip in the third sink and held it in the water for the manufacturer's recommended ten seconds. He removed the strip from the water and compared the strip to the package. The strip did not change color. The sanitizer was not at the recommended 200 parts per million (ppm) for effective sanitizing. Interview at the time of the observation revealed FSD #300 verified the dietary staff were currently washing dishes in the three sinks dish system. FSD #300 stated the three sink dish system used Quaternary solution for dish sanitizing. FSD #300 verified the Quaternary solution did not meet the minimum of 200 ppm for effective dish sanitation. Further interview with FSD #300 on 12/26/18 at 10:02 A.M., stated the facility policy does not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365807 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 365807 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Transitional Care Unit 200 St Clair Street Saint Marys, OH 45885 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 0812 address dating opened food. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled, Food Storage, revised 07/16, revealed foods must be protected from contamination, spoilage and other damage during storage. Foods stored in refrigerators should be covered, labeled and dated. All frozen foods should be labeled and dated. Residents Affected - Many Review of the manufacturer's instructions revealed the Quaternary solution must be 200 ppm concentration for effective dish sanitizing. Review of the Quaternary test strip instructions, revealed the proper testing method was to dip a test strip in the water and hold it for ten seconds. Remove the strip from the water and immediately compare the color. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365807 If continuation sheet Page 3 of 3