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. 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 12/12/2024 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)