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 (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: 366366 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 366366 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Healthcare Center 840 Sherman Street Geneva, OH 44041 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)