Failure to Label and Date Resident Food in Nourishment Refrigerators
Penalty
Summary
Surveyors observed that the facility failed to store food under sanitary conditions in both nourishment refrigerators located on the resident units. Specifically, food items brought in by visitors and family members for residents were found in the refrigerators without proper labeling or dating. On one floor, there were multiple unlabeled grocery bags and plastic containers, some of which were dated but lacked resident names, while others had neither dates nor names. Similar issues were found in the refrigerator on another floor, where several plastic bags with food items were also unlabeled and undated. Interviews with facility staff confirmed that these food items belonged to residents and were stored in the pantry refrigerators. The Assistant Director of Nursing acknowledged that food should be labeled with the resident's name and a discard date, and that perishable items should be discarded after three days. 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 staff are responsible for discarding perishable foods on or before the use-by date. The observed practices did not align with these requirements.
Plan Of Correction
Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Identified refrigerator on the second floor had 17 unlabeled grocery type bags with food items and three plastic containers in plastic bags with food items dated 05/29/2025 and had no names was discarded by the ADON 6/26/2025. Identified third-floor refrigerator with several unlabeled undated plastic bags with food items was discarded by the ADON 6/26/2025. 2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Quality review to be completed by the DON/designee of the 2nd and 3rd floor refrigerators to ensure food items brought in from outside visitors/family are dated, labeled and stored appropriately under sanitary conditions 7/22/2025. 3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; Current licensed nurses re-educated by the DON/designee on the components of this regulation and to ensure food items brought in from outside visitors/family are dated, labeled and stored appropriately under sanitary conditions 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; DON/designee to conduct ongoing quality monitoring of the 2nd and 3rd floor refrigerators through visual observation to ensure food items brought in from outside visitors/family are dated, labeled, and stored appropriately under sanitary conditions twice weekly x requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Identified refrigerator on the second floor had 17 unlabeled grocery type bags with food items and three plastic containers in plastic bags with food items dated 05/29/2025 and had no names was discarded by the ADON 6/26/2025. Identified third-floor refrigerator with several unlabeled undated plastic bags with food items was discarded by the ADON 6/26/2025. 2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Quality review to be completed by the DON/designee of the 2nd and 3rd floor refrigerators to ensure food items brought in from outside visitors/family are dated, labeled and stored appropriately under sanitary conditions 7/22/2025. 3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; Current licensed nurses re-educated by the DON/designee on the components of this regulation and to ensure food items brought in from outside visitors/family are dated, labeled and stored appropriately under sanitary conditions 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; DON/designee to conduct ongoing quality monitoring of the 2nd and 3rd floor refrigerators through visual observation to ensure food items brought in from outside visitors/family are dated, labeled, and stored appropriately under sanitary conditions twice weekly x four 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 then quarterly and PRN as indicated and modified based on findings.