Health inspection·October 3, 2024

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 facility policy review, observations, facility documents review, and staff interviews, it was determined that the facility failed to store food/beverages and utilize equipment in accordance with professional standards for food service safety in the kitchen and in three of three nourishment refrigerators; and failed to serve food in a sanitary manner during one of two tray line observations. Findings include: Review of facility policy, titled Refrigeration and Storage Procedures, with a last revised date of December 6, 2023, revealed, in part, Receiving Guidelines D. All food items will be stored with labels or markings designating: 1. Content; 2. Received Date; 3 Either a) manufacturer information (date/lot) or b) relevant disposal dates; E. Food items without the above information labels or markings upon arrival will have said dates added by staff; and Storage Guidelines A. General 2. Oldest stock will be rotated to the front to allow it to be used first, utilizing the FIFO [First in First Out] method. 3 All opened food items, including opened jars such as mayonnaise, will be: b) Dated with the initial opening date; D. Disposal of Food Items 2. Foods marked with a Best By, Use By, or Freshest Until Date will be kept and utilized after said date as per recommendations by the manufacturer or government resources. Observations of the kitchen on September 30, 2024, at approximately 10:38 AM, during a tour with Employee 2 (Dietary Manager) revealed the following: 1) in the dry storage room, there was a box of brownie mix with a best by date of July 12, 2024, with no other dates noted; a bag of sweet cornbread muffin mix with a best by date of December 28, 2023, with no other dates noted; five 104 ounce cans of diced beets with no dates noted; 16 104-ounce cans of diced carrots with no dates noted; four 2.25 pound cartons of dry hash browns with no dates noted; seven bags of butterscotch pudding mix with no dates noted; six boxes of chocolate cake mix with a best by date of May 10, 2022, and no other dates noted; two boxes of chocolate cake mix with a best by date of [DATE], and no other dates noted; and the scoop for the sugar bin was noted to be laying down in the sugar; 2) in the spice room, there was a bottle of opened vinegar with a best by date of May 23, 2024; nine plastic containers of chili powder with a best by date February 18, 2024; four plastic containers of oregano with a best by date of May 9, 2024, a plastic container paprika with a best by date of February 18, 2024; 3) in the walk-in freezer, there was a half full plastic bag of frozen diced green peppers that was Page 1 of 3 395583 395583 10/03/2024 South Mountain Restoration Cen Building #1 South Mountain, PA 17261

F 0812 secured with a twist tie, but there were no dates noted; Level of Harm - Minimal harm or potential for actual harm 4) in the walk-in refrigerator there was a case of unsalted butter with a best by date of December 4, 2023, with no other dates noted; Residents Affected - Some 5) in the walk-in beverage cooler there two cases of canned sliced pears, eight cans of sliced apples, and five cans of pear halves with no dates noted on the packaging; 6) in the vegetable walk-in freezer there was a bag of succotash laying on top of box with no dates noted and there was a case of sweet potatoes that had a large amount ice cover the top and side of the case; 7) in the walk-in freezer there two apple pies and approximately 15 chocolate cakes with no dates noted; 8) in the Cook's walk-in refrigerator there were approximately 10 cartons of thawed frozen liquid eggs with no dates noted; 9) in the Cook's Refrigerator 2 there was a half full plastic bag of diced celery that was secured with a twist tie, but there were no noted dates on the packaging. During an immediate staff interview with Employee 2, he indicated that they do not date items upon receipt into the kitchen. He also indicated that once a package was opened, that they should be dated with an open date. He also confirmed that all items observed that contained no dates were not dated in any manner. During a tray line food service observation on the sixth floor on October 2, 2024, at 11:47 AM, Employee 3 was observed leaving the tray line and opening the refrigerator with their right gloved hand. Employee 3 retrieved a package of sliced cheese from the refrigerator and returned to the tray line. Employee 3 was then observed to reach into an opened loaf of bread with their right gloved hand and retrieve two slices of bread with the same gloves. Employee 3 then removed the cheese from the package and placed it onto the bread, and placed the sandwich on the plate to be served to a resident. During an immediate staff interview with Employee 3 on October 2, 2024, at 11:49 AM, Employee 3 confirmed that the Employee should have changed gloves and washed hands, but the Employee focused on making the sandwich. Employee 3 then immediately left the tray line, removed their gloves, washed their hands, applied clean gloves, and returned to the tray line. During a staff interview on October 2, 2024, at 1:28 PM, with Employee 1 (Acting NHA/Chief Performance Improvement Executive), Director of Nursing (DON), and Employee 4 (Chief Operating Officer), Employee 4 indicated that facility staff had already had a meeting to discuss the food and beverage dating concern that was identified. Employee 4 shared that large bulk food items are placed in storage and dated when received there, and confirmed that once items are separated from the original packaging and delivered to the kitchen, the dates do not carry over with the items. Employee 1 confirmed that with the lack of dating at time or receipt/purchase, the facility could not utilize governmental guidelines at Foodsafety.gov as they are dependent on purchase dates to determine expiration dates. Employee 1 confirmed that Employee 3 should have removed their gloves, washed their hands, and applied new gloves after touching the refrigerator door handle. 395583 Page 2 of 3 395583 10/03/2024 South Mountain Restoration Cen Building #1 South Mountain, PA 17261

F 0812 Level of Harm - Minimal harm or potential for actual harm During a final staff interview with Employee 1, Employee 4, and the DON on October 3, 2024, at 10:24 AM, Employee 4 shared that the Employee 2 (Dietary Manager) and the storeroom managers had met and have devised a system to date items when received in the storeroom and a way to date items when they transition to the kitchen. Residents Affected - Some 28 Pa. Code 211.6(f) Dietary services 28 Pa. Code 201.18(b)(3) Management 395583 Page 3 of 3