Failure to Log Refrigerator Temperatures for Residents
Summary
The facility failed to properly log refrigerator temperatures for two residents with personal refrigerators in their rooms, which has the potential to affect all 58 residents in the sample. Observations revealed that the temperature logs for the personal refrigerators of two residents, R7 and R16, were missing documentation for several days in January 2025. Specifically, R7's temperature log was missing entries for multiple consecutive days, and R16's log was missing entries for four days. The Assistant Director of Nursing (ADON) stated that refrigerator temperatures must be checked daily to ensure proper operation and prevent food spoilage, which could lead to residents experiencing upset stomachs. During the survey, it was observed that R7's refrigerator contained food items and had a thermometer reading of 40 degrees Fahrenheit, which is within the acceptable range according to the facility's policy. R16, who has diagnoses including depression, obesity, chronic kidney disease, and atrial fibrillation, reported that staff clean the refrigerator but do not check it daily. R16's Brief Interview for Mental Status (BIMS) score indicated cognitive intactness. The facility's policy requires daily temperature checks by the 11-7 nurse at the start of the shift, but this was not consistently documented, leading to the deficiency.
Penalty
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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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