Health inspection·December 12, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure food was served and stored in a clean and sanitary manner. This had the potential to affect all 142 residents in the facility that consumed food from the kitchen. Findings Include: Observation of the kitchen area with Assistant Dietary Manager (ADM) #522 on 12/09/24 between 8:45 A.M. and 9:15 A.M. revealed the following that was observed and verified the time of discovery: 1. In the dry storage area an open packed of white rice with no date, an open bag of dinner rolls with no date, an open box of stuffing with no date, two containers of granulated sugar that were open with no date, an open box of bread crumbs with no date, and an open box of yellow cake with no date. 2. In the walk-in refrigerator two bags of open salad mix that were not sealed, an open package of pepperoni with no date, an open package of cheddar cheese with no date, an open package of tater tots with no date, and an open package of catfish with no date. 3. The fryer was noted to be extremely dirty with brown oil indicating the oil had gone bad and was not suitable for cooking food. ADM # 522 was stated I wouldn't eat out of that. Review of the undated dietary close down checklist posted on the dietary information board revealed before kitchen staff end their shift they are to ensure All items labeled & Dated-any items not labeled with date or name is to be discarded. Review of the undated procedure for dating food items posted on the outside of the [NAME] refrigerator and freezer All Opened Items Need To Be Put Into A Clear Bag Tied Off Or Container With A Lid. Placed A Label On Each Item Write The Items Name, Date It Was Opened and Expiration Date. This Must Be Followed For All Items. Page 1 of 2 366071 366071 12/12/2024 MT Alverna Home Inc 6765 State Road Parma, OH 44134

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a complete and accurate medical record for Resident #9. This affected one of twenty six sampled residents for medical record accuracy. Findings Include: Resident #9 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, heart failure and Parkinson's disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 was severely cognitive impaired and required hands on assistance of one staff person for completing activities of daily living such as toileting, transfers and bed mobility. The assessment further noted that Resident #9 required supervision for eating activities. Review of the most recent dietary notes dated 12/04/24 and 11/22/24 revealed concerns related to accuracy of weights related to a hospitalization and concerns related to variations of weights due to diuretic medications (medications that increase urination and can cause significant unintended weight loss quickly). No other dietary notations, assessments or other items were noted in Resident #9's medical for record for November and December 2024. Review of the census records for November 2024 and December 2024 revealed Resident #9 remained in the facility and was not sent to a hospital or any other acute care facility for any length of time. Interview with Dietary Technician (DT) #803 on 12/12/24 at 11:00 A.M. revealed (upon inquiry by the surveyor) DT #803 realized he had mixed up residents and had documented wrong resident's nutritional record into the medical of Resident #9. DT #803 was unsure what resident he documented the wrong information from. 366071 Page 2 of 2