Failure to Maintain Sanitary Conditions in Residents' Personal Refrigerators
Summary
The facility failed to ensure the safe and sanitary storage of food items in the personal refrigerators of two residents. For one resident, expired protein drinks were found in their personal refrigerator. This resident, who had severe cognitive impairment and required substantial assistance with activities of daily living (ADLs), was unaware of the expiration dates on the items in their refrigerator. Interviews with the Director of Nursing (DON) and the Administrator revealed that housekeeping and Certified Nursing Assistants (CNAs) were responsible for ensuring that residents' personal refrigerators were clean and free of expired food. However, this responsibility was not adequately fulfilled, placing the resident at risk of harm from consuming expired products. In the case of the second resident, their personal refrigerator was observed to be unclean, containing a brown and black substance with dead gnats. This resident, who had intact cognition and required supervision with ADLs, was aware of the unsanitary condition of their refrigerator but continued to consume food from it. Interviews with various staff members, including CNAs, housekeeping, and nursing staff, indicated confusion and lack of clarity regarding who was responsible for cleaning the residents' refrigerators. The DON and Administrator acknowledged that the facility's policy required family members to ensure cleanliness, but in their absence, facility staff were responsible. The facility's policy on personal refrigerators, dated 2012, stated that residents or their responsible parties were accountable for the care and maintenance of personal refrigerators. However, the policy also allowed for housekeeping to assist by inspecting refrigerators weekly and removing outdated food items. Despite this policy, the facility failed to implement it effectively, resulting in unsanitary conditions and expired food in residents' personal refrigerators, which could pose a risk to their health.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Several residents with personal refrigerators had food stored without consistent temperature monitoring or proper labeling, and expired food items were found during observations. Staff interviews revealed confusion over responsibility for monitoring, and the facility's policy lacked clear procedures for temperature checks, resulting in non-compliance with safe food storage practices.
Surveyors found that staff failed to monitor and safely store food brought in by families and visitors, resulting in unlabeled and moldy food items in a resident lounge refrigerator. The refrigerator was also found to be soiled and sticky, and there was confusion among staff about who was responsible for monitoring and discarding perishable foods, contrary to facility policy.
The facility failed to ensure safe handling and storage of food brought in from outside, affecting 41 residents. Observations revealed unlabeled and undated food items in resident refrigerators, lack of temperature monitoring logs, and improper storage of employee foods and breast milk. The facility's policy requires labeling and dating of all food items, with immediate disposal of unlabeled items.
The facility failed to provide adequate refrigeration for residents to store food brought in by family or visitors, affecting six residents. Residents reported no designated refrigerator for their use, and existing refrigerators were either full or for staff use. Observations showed unlabeled and undated items in a refrigerator, and the Dietary Manager confirmed the facility did not store outside food due to content uncertainty. The facility's policy allowed food from outside but did not ensure storage space availability.
Failure to Monitor and Maintain Safe Food Storage in Resident Room Refrigerators
Penalty
Summary
The facility failed to implement and enforce its policy regarding the use and storage of food in resident room refrigerators, specifically in relation to temperature monitoring for food safety. Observations and interviews revealed that several residents had personal refrigerators in their rooms, but there was inconsistency and confusion among staff regarding who was responsible for monitoring refrigerator temperatures. Some staff believed it was the responsibility of maintenance, others thought it was the CNAs, and some stated it was the nurses' responsibility. Multiple residents reported that their refrigerators were either not checked regularly or they were unaware of any monitoring taking place. Direct observations of the refrigerators in the rooms of four residents found that temperature monitoring logs were either missing, incomplete, or outdated. In one instance, a refrigerator contained expired food items, including a container of beef stew past its expiration date and a container of parmesan cheese that had expired over a year prior. The facility's policy required that food items be labeled, dated, and discarded after three days, and that unsafe or expired foods be removed by staff, but did not specify procedures for maintaining or monitoring refrigerator temperatures. The lack of clear procedures and consistent monitoring led to a situation where food safety could not be assured for residents storing personal food in their room refrigerators. The facility identified seven residents with personal refrigerators, but there was no systematic approach to ensure compliance with the policy or to safeguard against the storage of expired or unsafe food items.
Failure to Monitor and Safely Store Outside Food in Resident Refrigerator
Penalty
Summary
The facility failed to ensure proper monitoring and safe storage of foods brought in by family and visitors for residents. During an observation of the second-floor resident lounge refrigerator, surveyors found the exterior of the refrigerator heavily soiled with dried food, fingerprints, and a sticky handle. Inside, there was a paper plate with two cheeseburgers and an open package of microwavable chicken patties, both lacking resident names and dates. The chicken patties were visibly moldy and emitted a bad odor. Certified Nurse Aide (CNA) confirmed the presence of mold and the lack of labeling, stating that dietary staff were supposed to monitor the refrigerator. Further interviews revealed confusion regarding responsibility for monitoring the unit refrigerators, with the Dietary Director believing nursing staff were responsible. Review of the facility's policy indicated that perishable foods must be stored in resealable containers labeled with the resident's name, item, and use-by date, and that nursing staff are responsible for discarding perishable foods on or before the use-by date. The failure to follow these procedures had the potential to affect 36 residents on the second floor, with one resident identified as receiving nothing by mouth.
Deficiency in Safe Food Handling and Storage
Penalty
Summary
The facility failed to ensure the safe handling and storage of food brought in from outside for residents, which could potentially affect 41 residents who received food from the kitchen. During an observation, the Dietary Manager (DM) noted several issues with the resident refrigerator on the south resident hall, including three unlabeled and undated meat sandwiches, and a lack of temperature monitoring logs for the refrigerator. Additionally, the unit microwave was found to have dried food particles stuck to its ceiling and sides. These findings were confirmed by the DM at the time of observation. Further inspection of the resident refrigerator on the skilled hallway revealed multiple concerns, such as an unlabeled and undated plastic container of ice cream, an open and undated bottle of ketchup, and several other food items that were either expired or not labeled with a resident's name. An undated and unlabeled bag of employee-pumped breast milk was also found, which was against facility policy. The Assistant Director of Nursing (ADON) confirmed that employee foods and breast milk should not be stored in the resident refrigerator. The facility's policy mandates that all food brought in for residents must be labeled with the resident's name and date, and any unlabeled items should be discarded immediately. This deficiency was investigated under Complaint Number OH00159004.
Inadequate Refrigeration for Resident Food Storage
Penalty
Summary
The facility failed to provide adequate refrigeration for residents to store food brought in by family or visitors, affecting six residents. Residents reported that there was no designated refrigerator for their use, and the existing refrigerators were either full or intended for staff use. One resident mentioned being reprimanded for having homemade lemonade stored in the kitchen, which she eventually had to discard. Another resident noted that while there was a refrigerator at the nursing station, it had limited space and residents were not allowed to have personal appliances in their rooms. Observations revealed that the refrigerator on the 100 hall contained meals, soda, and condiments, none of which were labeled or dated. The Dietary Manager confirmed that the facility did not store food from outside sources due to uncertainty about its contents. The facility's policy stated that residents could bring in food as long as safe storage guidelines were followed, but it did not ensure the availability of storage space. This deficiency was investigated under Complaint Number OH00157418.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
