Deficient Food Handling and Storage Practices for Outside Food
Penalty
Summary
The facility failed to implement and enforce a safe food handling policy for foods brought in by visitors, resulting in several deficiencies. During an observation of a residents' refrigerator, multiple food items, including shrimp fried rice and chocolate chip ice cream, were found labeled only with room numbers and not with residents' names. The ice cream container was leaking inside a plastic bag, and the Infection Preventionist (IP) confirmed that labeling with only room numbers was insufficient, as residents may change rooms, and that the leaking ice cream should be discarded for infection control reasons. Additionally, food items belonging to a resident were found stored in a shared restroom's bathtub, including boxes of cookies and chicken noodles. Medical record reviews showed that the resident had intact cognition, but there was no documentation that the resident had been educated about the risks of storing food in a restroom. Staff interviews confirmed that the resident had hoarding tendencies and had declined to remove the food, and that there was no documentation of education provided regarding safe food storage. The facility's policy and procedure (P&P) for the use and storage of foods brought in by family or visitors did not address key food safety concerns such as time and temperature control, safe food handling, and preparation. Staff interviews and document reviews confirmed that the policy lacked these critical elements, and that nursing was only required to check for diet compatibility, not for food safety or proper storage.
Plan Of Correction
The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 49 was affected by this deficient practice. On 7/21/2025, the Unit Manager and Social Services met with the resident regarding his food storage and explained to the resident the risks of storing food items in a resident-shared bathtub. Resident 49 understood the risks, and the Interdisciplinary Team (IDT) updated the plan of care. All residents receiving outside food from family or visitors were affected by this deficient practice. On 8/5/2025, the Registered Dietitian (RD) and Dietary Supervisor provided the facility’s Policies and Procedures (P&P) to all residents receiving food from outside, and an educational flyer for food handling was given to families and visitors bringing food from outside. On 7/15/2025, food found unlabeled in Refrigerator A was discarded by the Infection Prevention (IP) nurse. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents were potentially affected by this deficient practice. The IP nurse checked all refrigerators for residents and found no other issues noted. From 8/5/2025 to 8/8/2025, the Registered Dietitian in-serviced all staff regarding the facility P&P for personal food policy, in particular ensuring any food from outside is labeled and stored appropriately. Education about food handling and the risks of bringing food from outside was provided to residents, family members, and visitors. The plan of care will be updated accordingly. Measures that will be put into place or systematic changes the facility will make to ensure that the deficient practice does not recur: The Administrator and RD or designee will oversee this process. The RD and Dietary Supervisor will discuss with all new admissions and their responsible parties during the initial care plan meeting about the personal food policy and will provide education about food handling if family or visitors plan to bring food from outside. Department heads and designees will conduct daily room rounds to check for any food stored in areas that are not appropriate for food storage and will educate residents about the facility P&P for storing food. Any non-compliant resident will be reported during the morning meeting, and the IDT will meet with the resident to develop a plan of care. The Dietary Supervisor or designee will check resident refrigerators daily to ensure food is properly labeled per facility P&P. Any non-compliant food labels will be discarded. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance: The Administrator will monitor the effectiveness of the process, and any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025