Health inspection·October 13, 2023

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 observations, review of dishwashing machine manufacturer's instructions, and staff interviews, it was determined that the facility failed to maintain dishwashing machine water temperatures in accordance with manufacturer recommendations for food service safety on three of three kitchenettes observed ([NAME], Gardens, and Springs). Findings include: Review of manufacturer's instructions for the facility dishwashing machine revealed that the hot water sanitizing mode minimum wash temperature and recommended wash temperature was 150 degrees Farenheit (F). Review of the Dishwashing/Warewashing machine temperature log sheet revealed that the temperature requirements for the wash cycle was: Wash 150 degrees F. If temperatures were not met per standard, fill out work order and notify management. Observations of the dishwashing machine operation on 10/11/2023, at 1:10 p.m. on the [NAME] unit, in the presence of the Dietary Aide Employee E1, revealed a dishwasher temperature of 144.2 degrees F during the wash cycle. Dietary Aide Employee E1 confirmed, at the time of observation, that the wash cycle was lower than the required 150 degrees F. Observations of the dishwashing machine operation on 10/11/2023, at 1:12 p.m. on the Gardens unit, in the presence of the Dietary Aide Employee E2, revealed a dishwasher temperature of 147.6 degrees F during the wash cycle. Dietary Aide Employee E2 confirmed, at the time of observation, that the wash cycle was lower than the required 150 degrees F. Observations of the dishwashing machine operation on 10/11/2023, at 1:15 p.m. on the Springs unit, in the presence of the Dietary Aide Employee E3, revealed a dishwasher temperature of 146.3 degrees F during the wash cycle Dietary Aide Employee E3 confirmed, at the time of observation, that the wash cycle was lower than the required 150 degrees F. Review of Dishwashing/Warewashing machine temperature logs for the Springs, [NAME], and Gardens kitchenettes revealed that Springs kitchenette dishwashing machine logged wash temperatures below 150 degrees F for multiple days and shifts in the months of September and October 2023. During an interview on 10/11/2023, at 1:30 p.m. the Dining Manager confirmed that dishwashing machine temperatures are supposed to meet the 150 degrees F during the wash cycle. Staff recording and (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: 395244 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 395244 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Saint Paul Homes 339 East Jamestown Road Greenville, PA 16125 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)