Health inspection·April 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 , interview, and record review the facility failed to store food in a sanitary manner for food safety. This had the potential to affect 64 residents who received nourishment by mouth. The facility census was 65. Findings include: Observation on 04/10/24 at 2:00 P.M. revealed the conference room refrigerator had undated squeeze tubes of mayonnaise, relish, mustard. Super Soft Pretzels and a four-quart Cookies and Cream ice cream tub was undated with no resident names on the food products. Interview on 04/10/24 at 2:00 P.M. with Dietary Supervisor #571 revealed resident food was stored in the employee breakroom and staff conference room to maintain safe food temperatures. Dietary Supervisor #571 verified the undated mayonnaise, relish and mustard squeeze tube, Super Soft Pretzels, and four-quart Cookies and Cream ice cream was not dated or labeled with resident names. Dietary Supervisor #571 also stated the kitchen did not purchase these food items. Observation on 04/10/24 at 2:10 P.M. of the 200 Unit nourishment refrigerator revealed two slices of pizza that was not dated or labeled with a resident name. Interview on 04/10/24 at 2:10 P.M. with Assistant Director of Nursing ( ADON)/ licensed practical nurse (LPN) # 507 revealed she was unsure if the pizza in the 200 Unit nourishment refrigerator belonged to a resident or staff member. ADON/ LPN # 507 also stated no resident had received any popsicles and if a resident wanted ice cream they would have to go to the kitchen. Snacks of a variety of sandwiches were delivered at 8:30 P.M. daily, if a resident wanted a sandwich stored the nurse would keep their food in the unit nourishment refrigerator in each nurse unit. Observation on 04/10/24 at 2:30 P.M. revealed the 100 Unit nourishment refrigerator had undated unlabeled Styrofoam container of pudding and undated and unlabeled pasta salad in the refrigerator. An undated, unlabeled Greek yogurt and an undated, unlabeled [NAME] Storm Energy Drink. Finally, a labeled peach tea with a staff member name in the resident nourishment refrigerator was observed. Interview with the ADON/LPN #507 verified there was no names or dates on the pudding, pasta salad, and Greek yogurt. She also stated the peach tea and Energy drink belonged to staff. Interview on 04/10/24 at 3:30 P.M. with the director of nursing (DON) revealed the facility used the employee breakroom, facility conference room and nurse unit nourishment refrigerator to store Page 1 of 2 366366 366366 04/12/2024 Pine Grove Healthcare Center 840 Sherman Street Geneva, OH 44041

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many resident food. The DON stated there was no central nourishment refrigerator to store resident food and maintain labels and dates. Review of facility policy title Use and Storage of Food Brought in by Family and Visitors (dated 11/21/16, revised 08/01/23) revealed food items that are already prepared by the family or visitor must be labeled and dated and the facility may refrigerate items in the nourishment refrigerator. 366366 Page 2 of 2