Health inspection·November 5, 2024

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observations, interview, review of facility menu and review of staff training, the facility failed to follow menus in regard to portion sizes and recipes in regard to food preparation. This affected 29 (#78, #80, #81, #82, #83, #86, #87, #88, #89, #91, #93, #96, #100, #101, #103, #104 #107, #108, #112, #113, #114, #115, #116, #118, #122, #123, #124, #125, and Resident #126) of 49 residents residing on the east wing of the third floor. Findings include: Review of the menu for the current week revealed lunch on 10/23/24 was chicken dumpling soup, country fried chicken with gravy, roasted potatoes and carrots, pudding, and milk. The portion size of the chicken dumpling soup indicated an eight ounce serving and to use an orange-colored scoop. Observations of meal service on the third floor servery on 10/23/24 at 12:15 P.M. revealed staff were plating country fried steak without the gravy. During the observation Dietary Director (DD) #201 asked the staff why are you not putting gravy on the steak? Dietary Aide (DA) #202 stated the gravy is not on the meal ticket so I wasn't sure if I should put it on the steak. DD #201 stated you guys are killing me! DA #202 then stated, I don't have anything to serve the gravy with. DD #201 then directed DA #202 to use the scoop with the holes it, it should be able to keep enough gravy to cover the steak. DA #202 followed the direction provided; however, the gravy, which was watery (like an au jus), ran through the holes and did not cover the fried steak. DA #202 and DD #201 verified using the scoop with holes was not effective. Continued observations at approximately 12:17 P.M. revealed DA #203 ladling soup into small bowels using a green scoop which provided 4.5 ounces. Most of the bowels were observed to have mainly broth and little to no chicken, dumplings or vegetables. When questioned, DA #203 said I am using the correct scoop, if I fill the bowl with more chicken, dumplings and vegetables, we will run out of soup quickly. DD #201 verified the wrong scoop size was being used to portion the soup for the meal. Review of the recipe for the brown gravy revealed staff were to brown flour into shortening, add water or stock gradually, stirring constantly with a wire whip: cook until smooth and thickened. Interview on 10/23/24 at 2:14 P.M., [NAME] #200 revealed no flour was available so corn starch was used to thicken the gravy. [NAME] #200 stated I can't make it the right way if I don't have the stuff. Review of staff training dated 10/16/24 revealed [NAME] #200, DA#202 and DA #203 received education including kitchen sanitation, proper food storage, tray prep/meal prep, and proper food temperature maintenance and serving. (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 5 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 11/05/2024 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)