Failure to Monitor and Approve Outside Food Leads to Resident's Death
Summary
The facility failed to ensure that a resident with difficulty swallowing and at risk for aspiration received care and monitoring of food consumption within the guidelines of the diet order. The facility did not implement its policy and procedure for food brought in from outside sources, which required that such food be shown to the Charge Nurse for approval to ensure it was within the diet order. Additionally, the facility did not provide the resident's family with the information sheet about bringing in food for a resident, nor did it ensure ongoing communication and coordination among staff to support the resident's nutritional well-being and safety. As a result, the resident consumed regular textured food brought in by a family member, which was not consistent with the prescribed pureed diet. The Certified Nursing Assistant (CNA) observed the resident eating the food but did not report it to the Charge Nurse. Subsequently, the resident became congested, had difficulty breathing, and became cyanotic. The resident became unresponsive and required cardiopulmonary resuscitation (CPR) but was pronounced dead shortly after. Interviews and record reviews revealed that the facility staff did not follow the established procedures for monitoring and approving outside food. The resident's diet and diet texture were not discussed during the initial interdisciplinary team (IDT) conference, and the family was not educated on the resident's special diet. The CNA did not intervene or report the incident when the resident was observed eating the wrong food texture, leading to the resident's adverse health event and subsequent death.
Removal Plan
- The Minimum Data Set (MDS) Nurse reviewed the diet orders of all current residents to determine if their diet texture and fluid consistency needed to be clarified with the physician. The MDS Nurse completed the clarification of diet orders.
- The Nurse Consultant provided an in-service to six Interdisciplinary Team (IDT) members to inform the resident's family, during the initial IDT meeting and subsequent IDT meetings as needed, about the resident's prescribed diet order and the facility's policy on Food for Resident from Outside Sources. The resident's family would be asked to sign a form acknowledging they received this information. The DON was the only remaining IDT member who would be provided with an in-service by the Nurse Consultant upon their return to work.
- The IDT reviewed current residents who were on a therapeutic diet and informed their family members via telephone conversation about the resident's prescribed diet order and the facility's policy on Food for Resident from Outside Sources. The information was provided using the family members' native language. The IDT members documented in the resident's chart that the family has been informed.
- Consultant provided an in-service to Registered Nurses (RNs), Licensed Vocational Nurses (LVN), Certified Nursing Assistants (CNA) and Restorative Nurse Aides (RNA), regarding the facility's policy on Food for Resident from Outside Sources and the different diet textures available in the facility. The in-service emphasized the following: Diet orders will be printed daily by the licensed nurse and will be made available as a reference at the nurses' station. Food brought in by family from outside sources must be consistent with the resident's prescribed diet; Food brought in by family from outside sources should be shown to the licensed nurse for evaluation if it matches the resident's prescribed diet. The licensed nurse must be notified if the resident is observed to be eating food that does not match the diet order or when the family is observed to have brought in food for the resident that is different from the diet order. The licensed nurse will check on residents who have food brought in by family every 2 hours and as needed; and, The licensed nurse will record both the evaluation of the food brought from outside and every two-hour visual checks in a log that would be submitted to the DON or designee for further review.
- Licensed nurses and CNAs were asked questions at the end of the in-service to evaluate their knowledge of the information provided in the in-service. In-services would be completed for all the active nursing staff by the Nurse Consultant. Staff who were currently on vacation or on leave will be provided the in-service upon their return to work.
- The Nurse Consultant checked competencies of RNs, LVNs and CNAs, as in identifying different diet textures by presenting them with different sample meal trays and asking them to correctly identify different diet textures and fluid consistencies. Competency evaluations would be performed by the Nurse Consultant and completed for all active nursing staff. Staff who were currently on vacation or on leave would have their competencies evaluated upon their return to work.
- The Nurse Consultant provided a one-to-one in-service with CNA 1 regarding the facility's policy on Food for Resident from Outside Sources, emphasizing the importance of reporting to the licensed nurse when the resident was observed to be eating food that was different from the diet order. At the end of the in-service, the CNA was asked questions to evaluate his knowledge about the information provided to him and was able to answer questions correctly.
- The Nurse Consultant provided an in-service to CNAs and RNAs regarding the importance of immediately reporting to the licensed nurse any observed changes in the resident's condition and acting upon any actions that do not match the facility's policy on Food for Resident from Outside Sources. The Nurse Consultant would complete the in-service for all the active CNAs and RNAs. Staff who were currently on vacation or on leave would be provided the in-service upon their return to work.
- The RD would review diet orders once a week to ensure diet orders were clear and correct. She would conduct rounds once a week to ensure that residents were provided the correct diet texture and fluid consistency. Findings would be reported to the Director of Nursing (DON) and Administrator weekly for follow-up.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident’s personal refrigerator contained expired [NAME] salami that was greyish and sitting in sour-smelling liquid, and the resident said he did not know it was spoiled and would have eaten it. The resident had vascular dementia, diabetes, and a hx of stroke with cognitive deficits, while staff gave conflicting accounts of who was responsible for checking resident refrigerators and removing expired food.
A resident's thermal bag in the residents' refrigerator contained perishable food, including raw organic kraut and another liquid container, that was not labeled with storage or expiration dates. The resident had cognitive impairment and needed assistance with several ADLs, while an LVN and the DSS stated refrigerated food should be labeled and dated to support food safety. The facility policy required visitor-brought perishable food to be clearly labeled and discarded after 48 hours if not consumed.
Unlabeled and undated food items were found in a resident nourishment refrigerator used for personal food storage, including opened and unopened dairy, salad, and frozen items with missing open dates or use-by dates. The DM and ADM stated no one was monitoring the refrigerator, and the facility policy required food brought in by family or visitors to be labeled, dated, and discarded if not used within 3 days.
The facility lacked a policy for personal food storage while rodent feces was observed in resident rooms and throughout the facility. Food items were stored in residents’ rooms, the owner reported an ongoing rodent infestation, and the DON and an LPN stated no education had been provided to residents or staff about reducing or controlling the infestation or food storage in rooms. The administrator stated there was no policy on personal food storage.
Unlabeled and undated food items were found in two residents’ personal refrigerators, including watermelon pieces and an opened cheese dip container with fuzzy patches. An RN confirmed the watermelon was not labeled or dated, and an LVN confirmed the cheese dip was also unlabeled and undated. The DON stated perishable items in residents’ refrigerators should be labeled and dated, and nursing staff were responsible for removing unlabeled or undated food items daily.
A resident refrigerator in the Activity/Dining Room was observed at 51 degrees F during an observation and interview with the DS. The DS stated the temperature should be 41 degrees F or below to keep food safe, and noted the food in the refrigerator had been brought in by residents' family and visitors. The facility policy required refrigerator temperatures to be 41 degrees F or below.
Spoiled, Expired Meat Left in Resident Refrigerator
Penalty
Summary
The facility failed to maintain safe and sanitary storage of a resident’s food items in a personal refrigerator. During observation, a package of [NAME] salami was found in Resident #71’s refrigerator with an expiration date of 05/10/26. The meat was greyish around the edges and there was a large amount of sour-smelling liquid in the container. The same spoiled, out-of-date salami was observed again during a later observation and interview, and Resident #71 said he did not know it was spoiled and would have eaten it. Resident #71’s record showed diagnoses including vascular dementia, diabetes, and cerebral infarction. The MDS indicated he was cognitively intact with a BIMS score of 14 and required setup or clean up assistance with eating, while the care plan also noted impaired cognitive and decision-making abilities due to a history of stroke with cognitive deficits. Staff interviews showed conflicting responsibility for cleaning resident refrigerators, with CNA, housekeeping, RN, DON, and the Administrator all discussing refrigerator cleaning and expired food removal, and the Administrator stated housekeeping had been overseeing the task. The facility policy stated foods must be received and stored in a manner that complies with safe food handling practices and that designated staff will maintain clean food storage areas at all times.
Unlabeled Perishable Food Stored in Resident Refrigerator
Penalty
Summary
The facility failed to ensure a container of 18 oz perishable raw organic kraut stored in a resident refrigerator was properly labeled with storage and expiration dates. During observation, a thermal bag in the residents' refrigerator contained boxed food items labeled with Resident 83's name, including the kraut in a dented plastic container without an expiration date and another container with approximately 1/4 of light-yellow liquid without a storage date. The resident's record showed Resident 83 was admitted with unspecified protein calorie malnutrition and had moderate impairment in cognitive skills for daily decision making, with dependence in several activities of daily living and supervision needed for eating. During interview, an LVN stated food stored in the residents' refrigerator should be labeled with storage and expiration dates because unlabeled food can spoil and pose a risk of foodborne illness if consumed. The Dietary Services Supervisor stated nurses should label food items stored in residents' refrigerators with the resident's name and the date the food was stored so staff can determine when it should be discarded. Resident 83 stated family brought food, staff placed it in a thermal bag in the residents' refrigerator, and the facility throws food away in two to three days if not consumed. The facility policy required food brought in by visitors to be clearly labeled with the resident's name and date received and stored, and refrigerated perishable food to be labeled, dated, and discarded after 48 hours if not consumed.
Unlabeled and Undated Food in Resident Nourishment Refrigerator
Penalty
Summary
The facility failed to maintain safe and sanitary storage of residents’ personal food items in the nourishment refrigerator used by residents in the dining room. During observation, the refrigerator contained multiple food items without required labeling or dating, including an unopened gallon of tea without a use-by date, an opened jar of applesauce without an opened date and with a use-by date of 07/14/2026, an opened package of muenster cheese without an open date or use-by date, an unopened container of cobb salad with a use-by date of 07/04/2026, and an opened bowl of cobb salad without an open date and with a use-by date of 07/04/2026. The freezer section also contained several items without proper dating, including an unopened frozen mini pizza with a use-by date of 07/16/2026, an unopened bag of frozen chicken nuggets with a use-by date of 03/06/2026, and two bags of sweet sauce without a use-by date. Interviews revealed the DM was unsure who was responsible for checking the refrigerator, stated no one had been monitoring the food, and said she had not paid attention to that refrigerator. The ADM stated the refrigerator was for residents to store personal food if they did not have a refrigerator in their rooms and confirmed that no one monitored the food in it. The facility policy required prepared food brought in by family or visitors to be labeled with content and date and consumed within 3 days or discarded by staff.
Lack of Policy for Personal Food Storage Amid Rodent Infestation
Penalty
Summary
The facility lacked a policy regarding the use and storage of foods brought to residents by family and other visitors, and the deficiency affected all 13 residents living in the facility. During an observation on 7/15/26 at 10:45 a.m., rodent feces was seen in resident rooms and throughout the facility, and fruit, bakery items, leftover meals, crackers, and granola bars were stored in residents’ rooms. The facility owner stated on 7/15/26 at 1:00 p.m. that there was an ongoing rodent infestation. The contracted exterminator stated on 7/15/26 at 1:30 p.m. that he was concerned about residents maintaining food caches in their rooms because of the rodent infestation. The DON stated on 7/15/26 at 2:40 p.m. that she had complained the week of 6/22/26 about unsanitary conditions and the rodent problem to the administrator and owners, and that no education had been provided to residents or staff to reduce or control the infestation, including food storage in residents’ rooms. An LPN stated on 7/15/26 at 3:25 p.m. that the facility had not provided education regarding reducing or controlling the rodent infestation. On 7/16/26 at 2:17 p.m., the administrator stated the facility did not have a policy on personal food storage, and a requested policy was not provided.
Unlabeled and Undated Food Items Found in Residents’ Refrigerators
Penalty
Summary
The facility failed to ensure safe and sanitary storage of residents’ food items in personal refrigerators for 2 of 5 residents reviewed. One resident’s refrigerator contained an unlabeled, undated container of watermelon pieces. The resident stated she had received the watermelon about 2 weeks earlier and had stopped eating it so she would not get sick, and said it would be helpful for someone to discard it. An RN confirmed the watermelon was undated and unlabeled and stated it was every staff member’s duty to check residents’ personal refrigerators to ensure items were safe to eat and to prevent food poisoning. Another resident’s personal refrigerator contained an unlabeled, undated, opened cheese dip container with unidentified fuzzy patches in shades of white. The resident was unaware of the container. An LVN confirmed the unlabeled, undated cheese dip was in the refrigerator and stated he did not know who was responsible for removing undated and unlabeled food items daily. The DON confirmed that perishable food and drinks in residents’ personal refrigerators should be labeled and dated, and stated nursing staff were responsible for removing undated, unlabeled food items from residents’ refrigerators daily and assisting families in labeling and dating food items brought in. The facility policy stated food or beverages brought in from the outside will be dated.
Resident Refrigerator Temperature Above Required Limit
Penalty
Summary
The facility failed to follow its policy and procedure for the use and storage of foods brought to residents by family and other visitors by not maintaining one resident refrigerator at the required temperature. During a concurrent observation and interview in the Activity/Dining Room, the resident refrigerator was observed at 51 degrees F, and the DS stated that refrigerator temperatures should be maintained at 41 degrees F or below to keep food safe for residents to eat. The DS also stated that the food items in the residents' refrigerator were brought in by residents' family and visitors. Review of the facility's policy titled, Refrigerator/Freezer Temperature Records, dated 1/1/2026, showed that refrigerator temperature must be 41 degrees F or below.
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