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F0921
D

Failure to Maintain Kitchen Safety During Ceiling Leak and Repairs

Pasadena, California Survey Completed on 10-19-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain proper food handling practices and kitchen safety standards, as evidenced by the continued use of a kitchen with a large, uncovered hole in the ceiling above food preparation and tray transport areas. The hole, measuring three by four feet, exposed pipes, drywall, wood framing, and a bent steel panel, and was located directly above the handwashing sink and food tray transport rack. Observations confirmed that food trays prepared for nearly all residents were transported under this exposed area, and additional leaks in the kitchen ceiling were being managed with wet towels and pans on the floor. Interviews with facility staff revealed that the water leak and subsequent ceiling damage had been present for several days, with the kitchen remaining in use throughout this period. The Assistant Director of Nursing and the Maintenance Supervisor provided conflicting accounts regarding when the leak and ceiling removal occurred, but both confirmed that food preparation continued despite the unsafe conditions. The Administrator relied on the opinion of plumbing contractors regarding kitchen safety, without consulting the Dietary Supervisor or other food safety professionals, and confirmed that food preparation continued even after the plastic tarp previously covering the hole was removed. The Dietary Supervisor stated that the kitchen should not be used for meal preparation when the ceiling hole was uncovered, citing the risk of contaminants falling into food. Despite this, the facility lacked a specific kitchen emergency plan or policy addressing situations where the kitchen is under construction or deemed unsafe for food preparation. The only relevant policy in place pertained to general disaster emergency preparedness, which did not cover the specific circumstances of kitchen safety during repairs.

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