Health inspection·August 11, 2023

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 and interview, the facility failed to ensure meals were served at a palatable temperature at point of service. This had the potential to affect all 39 residents who received meals from the kitchen. The facility identified eight residents (#1, #3, #4, #10, #16, #21, #22 and #23) as not receiving meals from the kitchen. The facility census was 47. Residents Affected - Many Findings include: Observation of tray line on 08/11/23 at 12:11 P.M. revealed Dietary [NAME] #147 was asked by the state surveyor for a test tray at the end of the 100-unit tray cart. At 12:11 P.M. Dietary [NAME] #147 plated a test tray. The test plate was enclosed by an insulated plate cover and base and placed in a covered uninsulated meal cart. Dietary [NAME] #147 proceeded to cook special order items for the remaining four meal trays for the cart where the test tray was sitting. At 12:22 P.M., the meal cart was delivered to the 100-unit by dietary staff, and state tested nursing staff began serving the meal trays to residents residing on the 100 unit at 12:27 P.M. At 12:45 P.M., all the residents had received their room meal trays. The test tray was taken out of the uninsulated cart at 12:45 P.M. by the Registered Dietitian (RD)#141 and taken the conference room. RD #141 proceeded to take food temperatures of the test tray using the facility's digital thermometer. The fish was 130.8 degrees Fahrenheit (F) and tasted warm and had good flavor; the cabbage and noodles was 118.3 degrees F had a good flavor, but was barely warm; the coffee was 133.4 degrees F and tasted warm; and the milk was 57.6 degrees F and tasted barely chilled. Interview was conducted during the completion of the test tray with RD # 141 who verified the temperature of the milk and cabbage and noodles were unsatisfactory. RD #141 felt the time it took for Dietary [NAME] #147 to cook special order items while meal trays were sitting in the cart, and the time it took for staff to pass trays had negatively impacted the test tray temperatures. This deficiency resulted from incidental findings during the investigation of Complaint Number OH00145184. 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: 366385 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 366385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury of Twinsburg 9928 Vail Drive Twinsburg, OH 44087 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)