Insufficient Dietary Staffing and Use of Untrained Support Personnel
Summary
The facility failed to ensure sufficient dietary support personnel were employed to safely and effectively carry out the functions of the food and nutrition service for 74 residents receiving meals from the kitchen. Review of the dietary schedule for a two-week period showed multiple days when only one staff member was scheduled for the morning shift. During an observation of the kitchen, two dietary staff were present, and one staff member reported that on many days they had to work short and that staff from other departments were brought in to help. She confirmed that these non-dietary staff were not trained on kitchen procedures and were only shown how to wash dishes. On another morning observation, only one dietary staff member was present in the kitchen preparing multiple breakfast items, including regular, chopped, and pureed foods, with no other dietary staff scheduled or present. This staff member confirmed she was working alone and that the Dietary Manager was aware in advance that she was the only person scheduled for that shift. She also stated that when she did not have help, the DON would send staff from other departments to assist with dishwashing. Another dietary staff member corroborated that the kitchen was often short staffed and that untrained staff from other departments were used to wash dishes, confirming they had not been trained in kitchen procedures.
Penalty
Resources
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Surveyors found that a kitchen employee was working without a clearly current and verified food handler certificate, in violation of facility policy requiring dietary staff to hold valid food handler permits within 30 days of hire. Records showed the employee’s prior certificate had expired, and the Dietary Manager acknowledged not noticing the expiration. When a new certificate was produced, its completion date conflicted with the date shown in the online verification system, and the Administrator could not explain the discrepancy, demonstrating a failure to ensure sufficient qualified food and nutrition service staff.
A non-employee visitor, the son of a cook, was allowed into the kitchen and was shown in a publicly accessible social media post actively assisting with kitchen duties, including handling beverage pitchers. The facility’s handbook requires employees to complete TB testing, orientation, and personnel file documentation, and specifies that visitors must enter through reception, be directed or escorted, and that employees are responsible for their visitors’ conduct. The Dietary Manager acknowledged the son was not an employee or volunteer and stated visitors were allowed only to visit in the back of the kitchen and were not permitted to touch food, yet the photo evidence confirmed the visitor was performing food service tasks, demonstrating that food and nutrition service functions were not limited to appropriately trained and authorized staff.
The facility failed to maintain sufficient dietary staffing to provide timely and adequate meal service, leading to repeated reports of late, cold meals and incomplete trays. Food Committee notes documented missing condiments, unannounced menu changes, posted menus not being followed, missing tray items, cold food, and running out of food before meal service ended. The interim dietary manager, who had allowed her CDM certification to lapse and had assumed the role after the prior CDM left abruptly, reported that there was not enough staff and that the RD was only on-site one day per week. Observations showed tray line assembly and meal delivery running significantly behind scheduled meal times, with only one cook, a cook in training, and one dietary aide on duty, and residents consistently reported that meals, especially those delivered to rooms, were late and cold and not reheated by staff.
Dietary staff lacked a current food handler cert for 1 of 11 staff reviewed. An employee was observed in the kitchen cleaning equipment and stated he would be preparing pure diets later that morning. The DS said the only cert on file was the one posted on the wall, while the Administrator later said HR had provided a current cert; however, online verification showed the cert had expired. The facility policy stated the dietary manager was responsible for ensuring dietary staff certs were current.
The facility did not ensure adequate dietary staffing, as only one Nutrition Services Manager was responsible for all kitchen functions, including manager, cook, and housekeeping roles. The facility assessment did not account for the number of cooks needed, despite two residents receiving oral intake in addition to tube feeding, one with frequent oral meals and another on a restricted-calorie diet. Because the Nutrition Services Manager worked every other day, meals were prepared in advance and reheated by an aide on days they were absent, rather than being freshly prepared each day. The Program Administrator confirmed that this was the only kitchen staff member, that concerns about staffing shortages and the need for a cook had been raised, and that there was no timely response from higher management.
The facility failed to ensure sufficient qualified dietary staff to prepare meals, as multiple dietary aides without cook certification were observed and reported to be cooking and baking for residents. Staff described being assigned to bake desserts and cook breakfast and lunch despite only holding food handler certificates, and one aide reported feeling scared to use the large oven. The Dietary Manager acknowledged that only she and one aide were qualified cooks, yet the schedule listed several food handlers as cooks, and these staff were actively preparing food and operating the tray line for residents receiving meals.
Expired and Unverified Food Handler Certification for Kitchen Staff
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a kitchen employee, Cook A, maintained a current food handler certificate as required for food and nutrition service staff. Record review showed Cook A had completed a Learn2Serve Food Handler Training Course with a certificate valid from 04/15/2023 through 04/14/2026. A staff list dated 04/29/26 indicated Cook A was hired on 01/14/26 and worked in the kitchen. During an interview, the Administrator stated she believed Cook A’s current food handler certificate was expired and would check for another certificate. The Dietary Manager reported that Cook A was scheduled to work that afternoon and had been instructed to complete his food handler training before returning to duty, and acknowledged he had not noticed that Cook A’s existing certificate had expired. Subsequent observation and record review showed the Administrator produced a food handler certificate for Cook A from The Always Food Safe Company that reflected a completion date of 04/22/2026 and validity through 04/22/2029, while online database verification for the same program showed a completion date of 04/29/2026 with validity through 04/29/2029. In a follow-up interview, the Administrator stated she was unsure why the dates on the physical certificate and the online verification were different. The facility’s policy, “Nutrition Services Personnel Guidelines,” revised 01/01/2026, stated that dietary employees should have food handler permits in accordance with local, state, and federal regulations within 30 days of hire. The survey findings concluded the facility failed to employ sufficient staff with appropriate competencies and skill sets to carry out food and nutrition service functions because Cook A did not have a current, clearly verified food handler certificate at the time of review.
Untrained Visitor Allowed to Perform Kitchen Duties and Handle Beverages
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dietary staff had appropriate competencies and that only qualified personnel carried out food and nutrition service functions. A cook’s son, who was not an employee or volunteer of the facility, was observed in a social media post assisting with kitchen duties, including handling beverage pitchers on a counter in the kitchen. The post, which remained publicly visible, included a caption from the cook thanking her son for coming to work with her to help her out. The Division of Quality Assurance received concerns about this situation and obtained photo evidence dated 03/30/26, showing the non-employee son in the facility kitchen handling beverages. Review of the facility’s employee handbook showed that employees are required to undergo a two-stage TB test upon hire, have a 6‑month orientation period, and have a personnel file with identifying information, health and training records, and reference checks. The handbook also states that all visitors should enter through reception, receive directions or be escorted, and that employees are responsible for the conduct and safety of their visitors. The Dietary Manager confirmed that the cook’s children were not employed or volunteering in the kitchen and stated that while the son sometimes visited his mother and was allowed in the back of the kitchen if wearing a hair net and staying near the exit door, visitors were not allowed to touch any food. The surveyor verified the kitchen location from the photo and confirmed with leadership that the social media posting showed the non-employee son actively working in the kitchen, which did not align with facility policies or competency and staffing requirements for food and nutrition services.
Insufficient Dietary Staffing Resulting in Late and Cold Meals
Penalty
Summary
The facility failed to provide sufficient dietary staff to safely and effectively carry out food and nutrition services, resulting in late and cold meals and incomplete tray service. Facility meal schedules showed designated serving times for both the main dining room and cart service, but Food Committee meeting notes from two separate months documented ongoing concerns about condiments not being on carts, lack of notice about menu changes, posted menus not being followed, missing items from trays, meals being late, food being cold, and running out of food before meal service was complete. The interim Dietary Manager reported that the Certified Dietary Manager had left the facility without notice, she had stepped into the role temporarily despite having allowed her CDM certification to lapse, and that the facility only had a Registered Dietitian on-site one day per week. She specifically stated there was not enough staff for the kitchen to run efficiently. Multiple residents reported that their meals were consistently cold, that meals delivered to rooms were late and cold, and that staff refused to reheat food in a microwave. During a confidential group interview, all participating residents confirmed that meals were consistently late and cold. Surveyor observations showed that on one observed day, tray line assembly was still occurring after the scheduled lunch start time, dining room residents did not begin receiving meals until later than scheduled, and cart delivery of trays to resident rooms did not begin until well after dining room service started. The acting Dietary Manager acknowledged that lunch was running about 30 minutes behind due to insufficient staff to prepare the meal on time, and staffing for that meal period consisted of one cook, one cook in training, and one dietary aide. The Nursing Home Administrator confirmed that the facility failed to provide sufficient dietary staff to perform essential kitchen duties.
Plan Of Correction
The facility will provide sufficient dietary staff to perform essential kitchen duties. On the assessment of the kitchen function, it was found that the facility was using an older menu which did not match the food ordering guide. Creating the need for frequent menu changes. The menu and order guide have now been reconciled, which will decrease the need for menu changes. The Tray Line will be moved from the dining room into the kitchen to improve time management, meal preparation and accuracy of meal including condiments needed. Education will be provided by the Administrator/Designee on the need for accuracy and time management for meal production. The Administrator will audit the kitchen meal production and accuracy weekly for four weeks and monthly for two results will be presented to the QAPI committee for review and recommendations
Dietary Staff Lacked Current Food Handler Certification
Penalty
Summary
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. The facility failed to employ sufficient staff with the appropriate competencies and skill set to carry out food and nutrition services for 1 of 11 dietary staff reviewed. Specifically, [NAME] I did not have a current Food Handler Certificate. Record review showed a Texas Food Manager Certification Program certificate dated 03/03/2021 with a handwritten expiration date of 03/03/2026 and the handwritten word "Keyed" with a check mark on the document. The facility staff list showed [NAME] I was hired on 06/18/25. During observation on 3/31/26 at 9:15 a.m., [NAME] I was in the kitchen cleaning a microwave and stated he would be preparing pure diets around 11 a.m. that morning. During interviews on 04/02/26, the DS stated the only food handler certificate he had for [NAME] I was the one hanging on the wall dated 03/03/2021 and that all staff were expected to have current food handlers certificates if they were working in the kitchen. The Administrator later stated HR had provided a current certificate, but record review of the online database showed the certificate number belonged to [NAME] I, with a course name of Texas Food Manager Exam English, an issue date of 03/02/2021, and an expiration date of 03/01/2026. The facility policy stated the dietary manager was responsible for ensuring food handler certifications were current for dietary staff.
Insufficient Dietary Staffing Resulting in Lack of Freshly Prepared Meals
Penalty
Summary
The facility failed to ensure sufficient dietary support personnel were available to carry out food and nutrition services, as identified through observation, interview, and record review. The facility assessment revised on 01/13/2026 did not plan for the number of cooks needed to meet food and nutrition service requirements. Physician orders showed that one resident was to take meals orally four times daily, and another resident had a restricted diet of 60 calories per day. Both residents received some oral intake in addition to tube feeding, with one resident on a plan to gradually discontinue tube feeding and the other receiving oral food for pleasure feeding. On 03/05/2026, the Nutrition Services Manager reported working alone in the kitchen and being responsible simultaneously for the duties of Dietary Manager, cook, and kitchen housekeeping. This staff member stated they prepared meals in advance for the following day because they only worked every other day, resulting in residents not receiving freshly prepared meals daily and having their meals reheated by an aide when the Nutrition Services Manager was not present. The Program Administrator confirmed that there was only one staff member assigned to the kitchen, acknowledged that this staff member had raised concerns about kitchen staffing shortages and the need for a cook, and stated that higher management had not provided a timely response to requests to hire additional dietary staff.
Unqualified Dietary Staff Used as Cooks and Bakers
Penalty
Summary
The facility failed to ensure there were sufficient qualified dietary staff available to cook meals for 127 residents who received meals from the kitchen. During interviews, multiple dietary aides reported that they were functioning as cooks or being required to perform cooking and baking tasks despite lacking cook certification. One former dietary aide stated that several individuals working as cooks did not have certification and that she was pressured to bake despite being a dietary aide and feeling scared to use the large, hot oven. During a kitchen tour, three dietary aides were observed performing meal preparation and tray line duties, including one aide who was cooking and plating breakfast while the others assembled and transported trays. The Dietary Manager reported that only she and one dietary aide were considered qualified cooks and that the remaining staff were food handlers, who she acknowledged were not supposed to prepare food because they had not taken the required classes. Despite this, the schedule listed several dietary aides as cooks, and staff interviews confirmed that food handlers were cooking breakfast and lunch and baking desserts. Documentation showed that most of these staff held only food handler certificates rather than cook certification, while the facility’s job description and safe food handling policy required appropriate procedures for preparing and cooking food in accordance with the FDA Food Code. The census showed 131 residents, with 127 receiving meals from the kitchen affected by these staffing and qualification issues.
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