Failure to Follow Policy for Reheating Outside Food
Summary
The facility failed to follow its own policy regarding the reheating of food brought in by family or visitors for one resident. Observation revealed that the resident, who was seated in her wheelchair at the bedside, reported a disagreement with the dietary manager after her food was burnt when staff previously warmed it in the kitchen. As a result, the dietary manager refused to warm her food in the kitchen. The resident further explained that microwaves had been removed from each floor and that residents were required to have outside food warmed in the kitchen. Interview with the dietary manager confirmed that there were no microwaves available for residents and that staff were not permitted to reheat outside food, a longstanding policy despite multiple resident complaints. Review of the facility's policy indicated that only dietary staff are allowed to reheat outside food to prevent injury.
Plan Of Correction
1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident Council Meeting to be held 7/2/2025 to review the policy r/t Food Brought in from Outside Visitors/Family. A copy of the Food Brought in from Outside Visitors/Family policy was placed in the admission packet by the ED 7/23/2025 and will be reviewed with new admissions, re-admissions and/or the resident representative as part of the admission process. Resident #13 grievance initiated and resolved 6/26/2025. Resident #13 educated on the policy r/t Food Brought in from Outside Visitors/Family by the ED 6/26/2025. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Quality review of grievances received over the last 30 days from residents/visitors and/or staff with concerns related to not being able to have their food re-heated to be completed by the ED 7/31/2025. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Current facility staff re-educated by the ED/designee on the components of this regulation and the policy titled "Food Brought in from Outside Visitors/Family" 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: The ED/designee to conduct ongoing quality monitoring through morning meeting r/t grievances regarding food not being able to be re-heated to ensure residents/visitors and staff have been provided education on the policy titled "Food Brought in from Outside Visitors/Family" 2 x weekly x 4 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 or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Personal Refrigerator Food Storage and Temperature Monitoring Deficiency: The facility failed to follow its policy for foods brought in by family and visitors for two residents. Surveyors found personal refrigerators with temps outside the required range, missing documentation, undated and unsealed food items, and one freezer without a thermometer. The Activity Director was responsible for checking and logging refrigerator temps, but staff interviews showed inconsistent oversight and uncertainty about acceptable refrigerator and freezer temperatures.
Incomplete Refrigerator Temperature Logs: A resident with COPD, chronic respiratory failure, and functional quadriplegia had a personal refrigerator log showing temperatures had not been checked for months. Staff interviews showed the DON, nurses, and management were responsible for checking and documenting the refrigerator temperature during room rounds, but the log was not completed as required.
No Refrigerated Storage for Outside Food: The facility failed to provide a refrigerator area for food brought in by family or visitors, despite a policy allowing such items to be stored in the food service dept. The Dietary Supervisor said staff stopped the food at the door and had no room for resident food, and Resident Council members reported there was no place to store it, so it had to be thrown away or eaten the same day.
Resident personal refrigerators in multiple rooms were found without internal thermometers, without current temperature logs, and in some cases with spilled brown fluid inside. Staff gave conflicting accounts of who was responsible for cleaning and monitoring the refrigerators, and the facility policy required designated staff to monitor food safety and document refrigerator temperatures.
A resident’s personal refrigerator contained an unlabeled, undated container of grilled chicken and Spanish rice that remained there during repeated observations. The resident, who had COPD, major depressive disorder, alcohol-related dementia, and moderately impaired cognition, said she was unaware the food was in the refrigerator and believed family had dropped it off during a visit. CNA and LVN staff confirmed the item was present, and the DON stated perishable food in residents’ refrigerators should be labeled and dated.
Improper Storage of Outside Food in Resident Refrigerator: A resident refrigerator in the activity room contained multiple unlabeled or expired food items, including meat tacos, pizza, watermelon, and mango slices. The DS, ADON, and DON stated outside food brought in by family should be labeled, dated, and discarded when expired or beyond 72 hours, but these items remained stored in the refrigerator without proper dates.
Personal Refrigerator Food Storage and Temperature Monitoring Deficiency
Penalty
Summary
The facility failed to have and follow a policy for the use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. Surveyors reviewed the personal refrigerators of two residents and found that both had temperatures outside the facility’s recommended range. One resident’s refrigerator repeatedly measured between 41 and 53 degrees, and the temperature log for that refrigerator also showed multiple days with no documented temperatures. The log was completed by the Activity Director. One resident had a history of schizoaffective disorder, BPH, protein calorie malnutrition, and moderate cognitive impairment with fluctuating inattention and disorganized thinking. His care plan addressed obsessive-compulsive behavior related to saving food, but it did not indicate that his personal refrigerator was monitored for expired foods, dated foods, or temperatures within acceptable parameters. Observations showed unsealed and undated cups of milk in the refrigerator along with bottled juice, and the refrigerator gauge remained at 50 to 52 degrees during repeated observations. The second resident had multiple sclerosis, paraplegia, atrial fibrillation, major depressive disorder, hypertension, neurogenic bowel, and moderate cognitive impairment. His room contained two personal refrigerators, but the temperature log reflected only one refrigerator and did not include the freezer. One freezer did not have a thermometer. Observations found food items in both refrigerators, including unopened and opened packaged foods and a cake with an illegible expiration date, while the refrigerator gauges ranged from 51 to 62 degrees and later 52 to 60 degrees. Staff interviews showed the Activity Director was responsible for checking the refrigerators, but she could not explain why temperatures outside the recommended range were not reported, and other staff were unsure who monitored the refrigerators or what the acceptable temperatures were.
Incomplete Refrigerator Temperature Logs
Penalty
Summary
The facility failed to follow its policy regarding the use and storage of foods brought to residents by family and other visitors by not maintaining completed documentation of temperature checks for Resident #1's personal refrigerator from November 2025 through June 2026. Resident #1 was an [AGE] year-old female with an initial admission date of 03/19/2020 and diagnoses including COPD, chronic respiratory failure, and functional quadriplegia. Her 05/25/2026 Quarterly MDS showed a BIMS score of 13, indicating intact cognitive function. During an observation on 06/30/2026 at 05:00 p.m., Resident #1's personal refrigerator log showed the refrigerator temperature had not been checked since November 2025. In interviews, LVN E stated management checked the refrigerator temperatures and that not checking the refrigerator could cause residents to get sick. The DON stated the refrigerator temperature should be checked daily and that management was responsible for checking it during rounds; she also stated she was responsible for checking the refrigerator. CNA B stated nurses were responsible for checking resident-room refrigerators, and ADON G stated refrigerators were checked by management and nurses, with the nurse logging the temperature and management verifying it was done. The DON later stated the refrigerator logs were done during room rounds and that she was currently doing the refrigerator check daily; Resident #1's refrigerator was the only resident refrigerator in the facility.
No Refrigerated Storage for Food Brought in by Family or Visitors
Penalty
Summary
The facility failed to ensure there was a refrigerated area for storing food brought in for residents by family and friends, despite having a policy titled FOOD FROM OUTSIDE SOURCES that stated food brought to residents by family, visitors, or volunteers is to be handled in a safe and sanitary manner and may be stored in the food service department in a refrigerator or freezer immediately. The policy also stated refrigerated cooked food not prepared in the facility is to be held no longer than 24 hours and labeled with the resident’s name, room number, date received, and discard date. On 06/23/2026, the Dietary Supervisor stated the facility did not keep items brought in by friends and family for individual residents, that dietary staff stopped the food at the door, and that dietary did not have room for resident food. At Resident Council on 06/24/2026, 11 of 11 members said there was no refrigerator available for residents’ food when family brought items in, and that the food had to be thrown away or eaten the same day. The council members also said dietary staff told them there was no place to put the food, and all 11 said residents wanted a refrigerator to store their food.
Resident Refrigerator Food Storage Not Monitored
Penalty
Summary
The facility failed to ensure the storage of foods brought to residents by family and other visitors was safe and sanitary for 10 rooms reviewed: 103, 108, 204, 213, 302, 303, 305, 403, 408, and 616. During observations, multiple resident personal refrigerators were found without internal thermometers and without logs documenting daily temperature checks. In some rooms, the refrigerators also had brown fluid spilled in the bottom, and one refrigerator was observed sitting on the floor of the room. Several of the refrigerators had no posted temperature log at all, while others had logs that were not current. In one room, the last documented temperature check was on 03/05/26, and in another room the last documented temperature was in December 2025. The observations showed that the facility was not consistently monitoring or documenting refrigerator temperatures in the resident rooms. During interviews, CNA-A stated residents or their families were responsible for keeping the refrigerators clean and that maintenance was responsible for monitoring temperatures. The Maintenance Director stated housekeeping was responsible for checking and cleaning the refrigerators and said no one had told him about monitoring them. Other CNAs, an LVN, and RNs gave differing responses about whether housekeeping, maintenance, dietary, or nursing staff were responsible. The ADON stated housekeeping and maintenance had previously been responsible, but the process stopped, and nursing staff should check food removed from the refrigerators before residents consumed it. The facility policy titled Resident Personal Food Storage stated that designated staff would monitor food safety, refrigerator units would have internal thermometers, and staff would monitor and document refrigerator temperatures.
Unlabeled Food Left in Resident Refrigerator
Penalty
Summary
The facility failed to ensure the safe and sanitary storage of a resident’s food items in 1 of 5 residents’ refrigerators reviewed. In Resident #84’s room, the personal refrigerator contained an unlabeled, undated container with grilled chicken and Spanish rice. The resident’s face sheet showed diagnoses including COPD, major depressive disorder, and alcohol-related dementia, and the BIMS assessment completed 2/10/26 showed a score of 12, indicating moderately impaired cognition. During observations on 6/16/2026 at 10:20 a.m. and again at 11:00 a.m., the unlabeled, undated food container remained in the refrigerator. Resident #84 stated she was unaware the container was there and recalled that family had visited on 6/13/2026 and likely dropped off the food. CNA D and LVN C both acknowledged the presence of the unlabeled, undated food item in the resident’s refrigerator, and LVN C stated nursing and administrative staff assisted residents in removing undated and unlabeled food items daily but she had not checked that day. The DON stated that perishable food and drinks in residents’ personal refrigerators should be labeled and dated, and that staff were responsible for removing undated, unlabeled food items daily.
Improper Storage of Outside Food in Resident Refrigerator
Penalty
Summary
Safe food storage practices were not ensured in one of two residents' refrigerators located in the activity room on the 2nd floor. During observation, the Dietary Supervisor identified a plate with three meat tacos, a container of pizza, a container of watermelon dated 6/11/26, and a cup of mango slices, all stored in the refrigerator without proper expiration dates or labeling. The Dietary Supervisor stated that food brought in by family members was placed in the residents' refrigerator and that expired or non-labeled foods should be discarded. Interviews with the ADON and DON showed that staff were expected to check the residents' refrigerator for temperature and food expiration dates, and that outside food should be labeled with the resident's name, room number, and date received. The ADON stated food items with an open date should be removed within 72 hours and that expired food should not remain in the refrigerator. The facility's policy for food from outside sources stated that outside food must be properly covered, dated, and labeled, and that perishable foods, leftover food, unused packaged food, and food beyond 72 hours from the received date or beyond the best buy date should be discarded.
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