Health inspection·December 14, 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 observation, interview, and record review the facility failed to provide palatable meals and failed to ensure food was served at adequate temperatures. This had the potential to affect all residents residing in the facility. The facility census was 151. Residents Affected - Many Findings include: Interviews on 12/13/23 from 9:18 A.M. to 9:55 A.M. with Resident #128 and Resident #14 revealed their meals were cold at times. Interview on 12/13/23 at 3:11 P.M. with Resident #141 revealed his meals were almost always cold, including his soups and coffee. Interview 12/13/23 at 3:16 P.M. with State Tested Nursing Assistants (STNAs) #208 and #210 revealed they were aware of multiple concerns related to cold foods. Interview on 12/13/23 at 3:20 P.M. with Resident #109 revealed his food was often cold. Resident #109 stated his family often provided him with food, and he had a microwave in his room to heat the food his family brought. Resident #109 stated, If it wasn't for my family, I would starve. Observation of meal service on 12/13/23 beginning at 4:45 P.M. revealed a pan of cut up chicken that was in chicken broth, a pan of cooked hamburgers that appeared to be old and dry, and a pan of golf ball sized dinner rolls that appeared to be dry and hard. Interview with Supervisor of Dining Services (SDS) #212 revealed meal plating usually began about 4:30 P.M. and she stated she had already obtained the temperatures of the food. Observation revealed a clipboard with no recorded temperature for the chicken or hamburgers, a temperature of 195 degrees Fahrenheit (F) for the soup, and the salad temperature of 35 degrees F. SDS #212 stated she had not written down the temperatures of the chicken; however, it was 183 degrees F, and she had not taken the temperature of the hamburgers or the pureed items. SDS #212 stated she was aware of concerns related to food temperatures and taste. A test tray was requested at 5:33 P.M. and was plated at 6:08 P.M., test tray consisted of a hamburger with a piece of unmelted cheese, French fries, and a bowl of soup. Test tray arrived to the floor at 6:12 P.M. and was received at 6:28 P.M. after the last resident tray was served. The temperature of the cheeseburger was 95 degrees F, French fries were 80 degrees F, and soup was 97 degrees F. Temperatures were verified by STNA #211. The test tray food was cold and lacking taste. Review of Resident Council Minutes for September and October 2023 revealed concerns related to cold food. This deficiency represents non-compliance investigated under Master Complaint Number OH00148622. 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: 366071 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 366071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MT Alverna Home Inc 6765 State Road Parma, OH 44134 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)