Failure to Follow Policy for Reheating Outside Food
Summary
The facility failed to follow its own policy regarding the reheating of food brought in by family or visitors for one resident. Observation revealed that the resident, who was seated in her wheelchair at the bedside, reported a disagreement with the dietary manager after her food was burnt when staff previously warmed it in the kitchen. As a result, the dietary manager refused to warm her food in the kitchen. The resident further explained that microwaves had been removed from each floor and that residents were required to have outside food warmed in the kitchen. Interview with the dietary manager confirmed that there were no microwaves available for residents and that staff were not permitted to reheat outside food, a longstanding policy despite multiple resident complaints. Review of the facility's policy indicated that only dietary staff are allowed to reheat outside food to prevent injury.
Plan Of Correction
1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident Council Meeting to be held 7/2/2025 to review the policy r/t Food Brought in from Outside Visitors/Family. A copy of the Food Brought in from Outside Visitors/Family policy was placed in the admission packet by the ED 7/23/2025 and will be reviewed with new admissions, re-admissions and/or the resident representative as part of the admission process. Resident #13 grievance initiated and resolved 6/26/2025. Resident #13 educated on the policy r/t Food Brought in from Outside Visitors/Family by the ED 6/26/2025. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Quality review of grievances received over the last 30 days from residents/visitors and/or staff with concerns related to not being able to have their food re-heated to be completed by the ED 7/31/2025. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Current facility staff re-educated by the ED/designee on the components of this regulation and the policy titled "Food Brought in from Outside Visitors/Family" to be completed by 7/31/2025. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The ED/designee to conduct ongoing quality monitoring through morning meeting r/t grievances regarding food not being able to be re-heated to ensure residents/visitors and staff have been provided education on the policy titled "Food Brought in from Outside Visitors/Family" 2 x weekly x 4 weeks, weekly x 2 weeks then twice monthly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Personal refrigerator food storage and temperature monitoring were not maintained for several resident rooms. Multiple refrigerators contained assorted food items, including dairy, condiments, sausages, and beverages, while no temp logs were found and internal temps were documented above the required range in some rooms. The ADM, DON, and DM stated residents or families were generally responsible for cleaning and maintaining the refrigerators, but there was no assigned daily staff task or log for monitoring temps or expired food.
The facility failed to ensure safe and sanitary storage and consumption of food brought in by family and visitors. Staff gave inconsistent answers about how long such food could remain in the nourishment refrigerator, while the facility policy stated that items without a manufacturer expiration date must be dated on arrival and discarded 2 days later.
No Designated Refrigerator for Food Brought in by Family or Visitors: The facility failed to follow its policy when it did not have a designated refrigerator for residents’ food brought in by family or visitors. CNAs were unsure where such food should be stored, the AA was unaware it could be stored in the activities refrigerator, and the DON confirmed the facility did not have a designated refrigerator despite the policy stating perishable outside food may be stored in designated unit refrigerators.
A resident with intact cognition and multiple medical diagnoses had a personal refrigerator containing an unlabeled, undated container with visibly spoiled contents, which remained in place on repeat observation. The resident reported storing snacks but was unaware of the requirement to date items and did not know about the container. The assigned CNA and LVN both confirmed the presence of the unlabeled, undated food and gave differing or incomplete understandings of responsibility for checking personal refrigerators, while the DON stated that all staff, overseen by charge nurses, were responsible for weekly monitoring and for ensuring perishable items in residents’ refrigerators were labeled and dated per facility policy.
Personal Refrigerator Not Maintained at Safe Temperature: A resident with Parkinson's disease and dementia kept meals in her room and had a personal refrigerator that was not cool on observation. Staff found the refrigerator at 48.9 degrees with no thermometer or temperature log, while the DON stated residents monitor their own refrigerators and nursing should help with the contents. The facility policy stated the refrigerator compartment should be maintained at 35-41 degrees.
The facility failed to follow its policy requiring daily temperature monitoring and documentation for residents’ personal in-room refrigerators and freezers used to store food brought by families and visitors. Several residents with multiple chronic conditions and varying cognitive status had personal refrigerators containing perishable items such as milk and ice cream, but temperature logs showed entries on only some days, with gaps where no temperatures were recorded. Although observed temperatures were within acceptable ranges at the time of survey, logs for multiple refrigerators were incomplete, and staff interviews revealed confusion over which department was responsible for daily temperature checks and that existing rounding tools did not instruct staff to verify refrigerator and freezer temperatures as required by policy.
Personal Refrigerator Food Storage and Temperature Monitoring Deficiency
Penalty
Summary
The facility failed to maintain safe and sanitary storage of residents’ food items in personal refrigerators for 4 of 21 resident rooms reviewed. During observations, multiple resident room refrigerators contained a variety of food items, including condiments, dairy products, sausages, cheese, yogurt, and beverages, while no temperature logs were located on or around the refrigerators. In one room, the refrigerator thermometer showed 42 F on two separate observations; in another room, it showed 46 F on two separate observations. In one refrigerator, food items included five bottles of grape and strawberry jelly, peanut butter, swirled peanut butter and jelly, soda, mayonnaise, sour cream, pickles, and water, with the internal temperature recorded at 42 F. In another refrigerator, four cans of soda and two containers of unknown food contents were present, and the thermometer showed 46 F. In a third refrigerator, two packs of hot link sausages were present, including one opened package and one unopened package, along with a bottle of mustard that had an open date written as 04/03/22 and a bottle of water. In a fourth refrigerator, items included snack packs with unknown white contents, yogurt, cream cheese spread, butter, chocolate bars, American cheese singles, mayonnaise, grape jelly, shredded cheese, and eleven cans of soda, including two damaged and misshaped cans. The ADM stated residents were responsible for maintaining their own personal refrigerators, including cleaning them, storing food properly, and discarding spoiled items, and said staff were not assigned to check personal refrigerators or document temperatures on a log. The DON stated staff could assist residents if needed and that expired or spoiled food could be discarded after notifying the resident and getting permission, but also stated there was no daily checklist or task assigned for staff to check refrigerators. The DM stated she placed thermometers in personal refrigerators and checked temperatures during morning rounds, but she did not keep temperature logs. The facility policy stated residents and/or responsible parties were responsible for care and maintenance of personal refrigerators, that housekeeping could assist at least weekly, and that food that is expired, spoiled, or moldy could be discarded.
Inconsistent Storage of Food Brought in for Residents
Penalty
Summary
The facility failed to ensure safe and sanitary storage and consumption of food items brought to residents by family and visitors according to its policy and procedure. During interviews on April 21, 2026, staff gave inconsistent answers about how long outside food could be kept in the nourishment refrigerator: one LVN said three days, a CNA said seven days, and another LVN said 24 hours to three days. Review of the facility policy titled, "BRINGING IN FOOD FOR A RESIDENT," dated 2023, showed that food or beverage items without a manufacturer's expiration date are to be dated upon arrival in the facility and thrown away two days after the date marked.
No Designated Refrigerator for Food Brought in by Family or Visitors
Penalty
Summary
The facility failed to follow its policy and procedure titled "Foods Brought in by Family or Visitors" when it did not have a designated refrigerator for residents’ food brought in by family or visitors. During interviews, CNA 1 stated she believed residents could receive food from visitors or family but was not aware of the process or where to store that food. CNA 2 stated she believed residents’ food brought in from family could be kept in the activities refrigerator, but also said she did not know where residents would put their food. The Activities Assistant stated she was not aware that residents’ food could be stored in the activities refrigerator. The DON stated the facility did not have a designated refrigerator for residents’ food brought in from the outside. During record review, the policy dated 4/10/2026 stated that perishable food brought in from outside sources may be stored in designated unit refrigerators, but the DON stated the facility no longer had a designated refrigerator for food brought in for residents from the outside.
Failure to Monitor and Label Food in a Resident’s Personal Refrigerator
Penalty
Summary
The facility failed to ensure safe and sanitary storage of food items in a resident’s personal refrigerator, as required by its policy. Record review showed the resident had intact cognition with a BIMS score of 15 and diagnoses including Major Depressive Disorder, Hypertension, and Benign Prostatic Hyperplasia. During observations of the resident’s personal refrigerator, surveyors found an unlabeled, undated storage container with unidentified contents showing fuzzy, slimy patches in shades of green, black, and white. A subsequent observation shortly afterward confirmed the container remained in the refrigerator. In interviews, the resident stated he stored snacks in his personal refrigerator but was unaware that items had to be dated and was unaware of the unlabeled container. The CNA assigned to the resident confirmed the presence of the undated, unlabeled container and stated she did not know who was responsible for checking the resident’s personal refrigerator for expired food. The LVN assigned to the resident also confirmed the presence of the unlabeled, undated container and stated that all staff were responsible for removing such items from residents’ personal refrigerators weekly. The DON confirmed that perishable food and drinks in residents’ personal refrigerators should be labeled and dated, that all staff were responsible for removing undated and unlabeled food items weekly and assisting families with labeling and dating food brought in, and that charge nurses were responsible for overseeing this task in accordance with the facility’s “Personal Refrigerator” policy, which requires weekly monitoring of resident refrigerators.
Personal Refrigerator Not Maintained at Safe Temperature
Penalty
Summary
The facility failed to help family and visitors understand safe food handling practices for Resident #8's personal refrigerator and failed to ensure the in-room refrigerator met safe cooling and reheating temperature standards. Resident #8 was an [AGE]-year-old female admitted on [DATE] with Parkinson's Disease without Dyskinesia and secondary dementia in other diseases classified elsewhere. Her care plan dated 04/06/2026 stated she was on a regular diet, chose to eat all meals in her room, and required monitoring and documentation of meal intake. Her quarterly MDS assessment dated [DATE] showed a BIMS score of 12, indicating moderate cognitive impairment, and Section GG indicated she needed setup or clean-up assistance for eating. On 04/14/2026 at 11:00 AM, observation showed Resident #8 had a personal refrigerator in her room that did not feel cool when opened, and there was no inside thermometer or temperature log. Later that day, the Maintenance Supervisor checked the refrigerator and found the temperature was 48.9 degrees, with the control set to 1. The Maintenance Supervisor stated on 04/16/2026 that the family member or responsible party was responsible for maintaining personal refrigerators. The DON stated on 04/16/2026 that residents monitor their own refrigerators, nursing should help with the content, and direct care staff should throw away spoiled food. The Housekeeper Supervisor stated personal refrigerators were cleaned by housekeeping when alerted by the DON, and housekeeping would remove expired items with the resident present. The facility policy for Personal Refrigerator stated housekeeping can assist the resident and/or family member by inspecting refrigerators at least weekly and that the refrigerator compartment should be maintained at 35-41 degrees.
Failure to Perform Daily Temperature Monitoring of Residents’ Personal Refrigerators
Penalty
Summary
The deficiency involves the facility’s failure to implement its policy for monitoring and documenting temperatures of residents’ personal in-room refrigerators and freezers used to store food and beverages brought in by families and visitors. The written policy, dated 01/01/2025, required that a temperature monitoring log be maintained, that a designated staff member document refrigerator temperatures daily, and that a thermometer be kept in the refrigerator to maintain a temperature of 41 degrees or below. Surveyors found that temperature checks were not being performed and documented daily as required, despite residents having personal refrigerators containing perishable items. For one resident with COPD, deep vein thrombosis, schizophrenia, and depression, who had intact cognition with a BIMS score of 13, observation showed a personal refrigerator containing a gallon of milk with a valid expiration date. The temperature log taped to the side of the refrigerator showed entries only on four dates, rather than daily, and all recorded temperatures were 32 degrees. The thermometer inside the unit read 32 degrees in the refrigerator and 22 degrees in the freezer at the time of observation, which were within acceptable parameters, but the monitoring was not done every day. The resident stated he did not know who checked the thermometer and did not recall having spoiled food. For another resident with cervical disc degeneration, cerebral infarction, aphasia, hypertension, and chronic kidney disease, and a BIMS score of 3 indicating severe cognitive impairment, observation revealed a personal refrigerator with three pints of ice cream in the freezer, all with future expiration dates. The temperature log showed checks on only three dates, with refrigerator and freezer temperatures within acceptable ranges, but again not documented daily. A third resident with diabetes type II, unspecified chronic bronchitis, and spinal cord disease, and intact cognition with a BIMS score of 15, had a personal refrigerator log with missing temperature entries for two consecutive days, indicating temperatures were not obtained daily. This resident reported that staff did not always keep up with temperature checks, though they looked at the refrigerator daily. Interviews with the DON, Housekeeping Supervisor, and Administrator confirmed that nursing staff were not responsible for monitoring these temperatures, that housekeeping had not been clearly informed of this responsibility until after the survey date, and that the Ambassador Round sheet used by staff did not direct them to check refrigerator and freezer temperatures, resulting in the failure to carry out the facility’s policy.
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