F0812 F812: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F

Unsanitary food handling and improper storage of expired and unlabeled food items

Wesley Enhanced Living - DoylestownDoylestown, Pennsylvania Survey Completed on 03-05-2026

Summary

The facility failed to store and serve food in a sanitary manner in the dietary department, the activities room kitchenette, and on Nursing Unit N2. Facility policy on bare hand contact with food and use of single-use gloves required staff to change gloves as often as necessary to remove soil and contamination, prevent cross contamination when changing tasks, and change gloves any time a contaminated surface was touched. During observation of meal service in the satellite kitchen on N2, a dietary employee handled and cut grilled sandwiches with gloved hands, touched the handle of the grill/oven, and then handled the sandwiches again without changing gloves. The same employee also prepared bread with peanut butter, walked to another station to retrieve jelly, and returned to the sandwich preparation without changing gloves. The dining services manager confirmed the employee should have changed gloves and performed hand hygiene between tasks. Facility policy on foods brought by family or visitors required food to be labeled and stored to distinguish it from facility-prepared food and required staff to discard food past its expiration date. In the activities room kitchenette refrigerator, surveyors observed an opened bottle of salad dressing that was not labeled and shelving with debris and a dried light-yellow substance. In the kitchenette cabinets, surveyors found multiple unlabeled or undated items, including a bottle of cinnamon sticks with an expiration date of December 29, 2020, ground nutmeg with an expiration date of December 27, 2024, a thick yellow substance in a bottle that was not labeled or dated, a paper bowl with a lid containing a powdered substance that was not labeled or dated, cream of tartar with an expiration date of November 20, 2024, a can of pumpkin puree with an expiration date of December 29, 2025, and several packets of thickening powder with expiration dates of November 3, 2025, April 10, 2025, October 11, 2024, and March 9, 2023. The Nursing Home Administrator confirmed the items should have been labeled and dated, the shelving should have been clean, and the expired items should have been discarded.

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.

Resources

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See other F0812 citations
Unsafe Food Storage and Dishwashing Practices
F
F0812 F812: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Short Summary

Unsafe Food Storage and Dishwashing Practices: Surveyors observed dented cans in dry storage, a walk-in freezer at 10 F with ice cream, buns, and popsicles soft or showing signs of melt/refreeze, and a handwashing sink trash can that required hand contact to open. Staff were seen carrying used paper towels across the kitchen to overflowing trash cans, and a Dishwasher moved between dirty and clean dish tasks, handled cigarettes in a puddle, and unloaded clean items without changing gloves or performing hand hygiene. The DON/Administrator and Dietary leadership acknowledged the concerns during interview.

No penalty information released
tooltip icon
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.
Kitchen Food Storage and Sanitation Failures
E
F0812 F812: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Short Summary

Kitchen staff failed to follow food storage and sanitation standards when unlabeled, undated food items were found in the walk-in freezer and refrigerator, an uncovered garbage can was observed next to the prep table, and a DC was not wearing a hair restraint over his mustache area. Staff interviews confirmed that labeling, dating, covering the garbage can, and wearing hair restraints were expected responsibilities, and facility policies required covered, labeled, and dated refrigerated and frozen foods as well as proper personal cleanliness in food prep areas.

No penalty information released
tooltip icon
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.
Food Storage, Labeling, and Hand Hygiene Failures
F
F0812 F812: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Short Summary

Food storage, labeling, and sanitation practices were not followed in the kitchen. Sanitizer buckets tested outside the manufacturer range, numerous prepared and packaged foods were found unlabeled, missing open or use-by dates, or expired across multiple storage areas, and a cook handled raw chicken with contaminated gloves after touching a speaker without removing the gloves or performing hand hygiene.

No penalty information released
tooltip icon
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.
Improper Hair Restraints During Food Preparation and Service
E
F0812 F812: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Short Summary

Improper Hair Restraints During Food Preparation and Service: Kitchen staff were observed serving and preparing meals without properly covering all hair. One staff member wore a beanie that left braids uncovered while assisting with the noon meal, and another wore a headband with hair uncovered while preparing the noon meal. Interviews confirmed staff understood hair restraints were required to keep hair out of food, and the facility policy required all employees in food prep areas to wear a hairnet or hair covering.

No penalty information released
tooltip icon
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.
Unsafe Food Storage in Kitchen and Nourishment Room Freezer
D
F0812 F812: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Short Summary

Unsafe food storage was identified in the main kitchen and in 1 of 2 nourishment rooms. The walk-in freezer had no stand-alone thermometer, and the 300 Hall nourishment room freezer registered 30 degrees Fahrenheit with 7 thawed ice cream bars stored inside. The Kitchen Manager acknowledged the missing thermometer and confirmed the thawed items.

No penalty information released
tooltip icon
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.
Food Storage, Labeling, and Kitchen Sanitation Deficiencies
F
F0812 F812: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Short Summary

Food storage, labeling, and sanitation deficiencies were observed in the kitchen and a serving kitchenette. Undated and unlabeled food items were found in refrigerators and freezers, milk was present past its best-by date, food debris and sticky residue were noted in freezer areas, a ceiling vent was dirty, and cooks with beards were observed without beard nets. The DD verified the findings, and staff stated items past date should be discarded and food items should be labeled and dated when stored.

No penalty information released
tooltip icon
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.
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