Failure to Maintain Safe Temperatures and Monitoring in Nourishment Room Refrigerators
Penalty
Summary
The deficiency involves the facility’s failure to maintain safe refrigerator temperatures and complete temperature monitoring in all four nourishment room refrigerators, contrary to its own policy titled "Refrigerators and Freezers" revised December 2022. The policy requires refrigerator temperatures to be maintained between 35°F and 40°F, freezers at less than 0°F, and mandates monthly tracking sheets for all refrigerators and freezers with documentation of corrective actions when temperatures are out of range. Review of the December 2025 temperature log for the Damascus unit nourishment room refrigerator showed that all six recorded temperatures were above 40°F, and no data was recorded for days 7 through 9. In addition, an observation of the Damascus unit nourishment room refrigerator revealed there was no thermometer present to measure the internal temperature. Similar issues were identified in the nourishment room refrigerators on the Bethal and two other named units. For the Bethal unit, the September 2025 temperature log had no data recorded for days 28 through 30, and the December 2025 log showed two of four recorded temperatures above 40°F with no data recorded for days 5 through 9. For one unit, the September 2025 log had no data for days 26 through 30, and the December 2025 log showed three of four recorded temperatures above 40°F with no data for days 5 through 9. For another unit, the September 2025 log had no data for days 19 through 20 and 23 through 30, and the December 2025 log showed four of four recorded temperatures above 40°F with no data for days 5 through 9. During interviews, the Culinary Manager and Registered Dietician stated that kitchen staff are responsible for checking nourishment rooms on each unit, and a supervisor aide checks behind them for expired items and temperature logs, noting that the person currently assigned to check the nourishment areas is new. The Administrator stated her expectation that kitchen staff assist with monitoring nourishment room temperatures and stocking, with nursing staff helping, and that training is provided during orientation, annually, and as needed.
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