Health inspection·September 5, 2019

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on observation, staff interview, and review of facility policy, the facility failed to label, date, cover and discard outdated foods items from the walk-in refrigerator and freezer. This had the potential to affect all 36 residents who resided in the facility and receive food from the kitchen. Findings include: On 09/03/19 at 8:16 A.M., an initial tour of the kitchen was conducted with Dietary Supervisor (DS) #100. During the observation the following concerns were verified by DS #100: a. In the freezer there was a bag of steak fries with no date of opened or a use by date. b. In the freezer there was a bag of fish with no date of opened or a use by date. c. In the freezer there was a ham rewrapped with no date or used by date. d. In the freezer there were eight bags of soup vegetables with no date or used by date. e. In the refrigerator there was a tray with 13 slices of apple spice cakes on a cart that were uncovered with no date or used by date. f. In the refrigerator on a tray there were seven cream puffs on a cart uncovered with no date or used by date. g. In the refrigerator there were a bag of carrots with a prep date of 08/25/19 and a used by date of 09/01/19 Interview on 09/03/19 at 8:30 A.M., DS #100 stated foods should be covered, labeled and dated. 2. Observation on 09/04/19 at 3:00 P.M., revealed Dietary [NAME] (DC) #200 took off plastic gloves and placed them on the counter to get a spatula for the pureed desert. DC #200 placed the spatula on top of the plastic gloves and proceeded to use the edge of the spatula to cut a piece of pie and place in the blender. Interview on 09/04/19 at 3:05 P.M., DC #200 reported she did not realize she had placed the spatula on top of the plastic gloves. DC #200 verified findings. (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 2 Event ID: 366223 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 366223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Notre Dame Health Center 699 East Columbia Avenue Cincinnati, OH 45215 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)