F0865

E

Failure to Use QAPI to Monitor Temporary Food Service After Elevator Outage

Monterey Park, California Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement a QAA/QAPI plan to monitor and manage changes in food service operations after the kitchen elevator became inoperable. The elevator, which connected the basement kitchen to upper floors, had been broken since the last quarter of 2024, and staff began transporting food and beverages via the stairwell and using the conference room as a food distribution and serving area. Despite this significant operational change, the facility did not establish a performance improvement project or monitoring system under QAPI to oversee sanitation, infection control, or safety related to this temporary food service arrangement.

Surveyors observed multiple issues in the temporary conference room service area and in the process of transporting and receiving food. In the conference room, a sandwich with an expiration date of 2/22/26–2/23/26 was found stored in a reach-in refrigerator past its use-by date. During lunch service, cold beverages were out of temperature range, with apple juice at 46.9°F and milk at 52.5°F, while the Dietary Supervisor acknowledged that cold foods and beverages should be at 41°F or below and that the conference room was warm and lacked ice for proper cold holding. The Registered Dietitian’s monthly sanitation audits were limited to the kitchen and did not include the conference room where food was being temporarily served.

Additional observations and interviews showed that staff were manually carrying beverages and large pans of food up the stairs from the basement kitchen, and food vendors were leaving deliveries in the parking lot for staff to bring down the stairwell to the kitchen. The Dietary Supervisor reported that only one staff member had been injured during this period and acknowledged that no in-services on fall injuries or fall prevention had been provided, and that staff were not routinely trained in injury risk prevention while delivering food via the stairwell. The Administrator confirmed that while the elevator outage was discussed in monthly QA meetings, there was no documentation of a performance improvement project or monitoring of sanitation and infection control in the conference room, nor ongoing training and evaluation of staff skills and knowledge related to the new food transport and service procedures, despite facility policy requiring the QAA committee to identify quality issues, implement corrective plans, and monitor performance.