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, interviews, and policy review the facility failed to serve food at an appropriate
temperature. This affected the 22 residents observed for lunch service, Residents #22, #23, #24, #25, #26,
#27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, and #43. Census was 43.
Residents Affected - Some
Findings include:
Observations on 12/13/25 at 12:55 P.M. revealed a test tray left the kitchen with resident meals trays and
arrived at the unit at 12:59 P.M. Certified Nurse Assistant (CNA) #102 started passing the meal trays to the
residents at 1:09 P.M. At 1:29 P.M., after the last resident was served, the test tray was sampled. The
temperature of the roast beef and mashed potatoes was 100 degrees Fahrenheit. The roast beef was dry
and the gravy was salty. The food temperatures were verified by CNA #102.
The residents who received meal trays from the food cart with the test tray included Residents #22, #23,
#24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, and #43.
Interviews on 02/13/25 from 1:33 P.M. to 1:40 P.M. with Resident #33, #34, and #43 revealed the food was
not hot, it was warm. The residents also stated the meat was dry.
Review of the facility policy Record of Food Temperatures, dated 2023 revealed foods were to be held at
135 degrees Fahrenheit or greater.
This deficiency represents non-compliance investigated under Complaint Number OH00162594.
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:
366289
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
366289
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/13/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Concordia at Sumner
970 Sumner Parkway
Copley, OH 44321
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)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observations, interview, and policy review the facility failed to serve food in a sanitary manner.
This had the potential to affect all residents who ate meals prepared in the kitchen. The census was 43.
Residents Affected - Many
Findings include:
Observations on 02/13/25 from 12:03 P.M. to 12:55 P.M. revealed [NAME] #100 plating food and Kitchen
Aide (KA) #101 placing food trays consisting of open roast beef sandwiches with mashed potatoes, gravy,
fruit cup and coleslaw into the food cart for transportation. KA #101 did not cover the fruit or coleslaw before
putting the trays in the transport cart. [NAME] #100 was observed donning and doffing gloves throughout
lunch service without washing his hands between glove changes. In addition, after donning clean gloves
Cook#100 was observed opening refrigerator doors, kitchen drawers and picking up non-food items then
picking up food items. [NAME] #100 was observed picking up the mechanical altered roast beef with a
gloved hand and spreading it on the bread. A cell phone charger and cell phone were observed on the
serving counter amongst beverages and food items to be placed on the meal trays. An interview with
[NAME] #100 at the time of the observation revealed a scoop was available which he could retrieve and use
for placing the roast beef onto the bread.
Review of the facility policy titled Food Safety Requirements, dated 2023 noted food should be covered
when traveling down the hallway. Gloves should be worn when directly touching ready-to-eat foods, and
staff should not touch food with bare hands, exhibiting appropriate use of gloves, tongs, deli paper, and
spatulas.
Interview with the Director of Nursing on 02/13/25 at 3:45 P.M. revealed all residents received food served
in the kitchen. There were no residents who had orders to receive nothing by mouth.
This deficiency represents non-compliance investigated under Complaint Number OH00162594.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366289
If continuation sheet
Page 2 of 2
