Kitchen Staff Failed to Follow Meal Ticket and Identify Fortified Food Substitutes
Summary
The facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills related to following meal tickets and identifying substitute fortified food items. During a concurrent observation and interview in the trayline for lunch, CK 1 placed shredded cheese and extra shredded cheese on Resident 67’s tray even though the meal ticket indicated the resident disliked cheese. CK 1 stated she failed to check the meal ticket and should have reviewed and followed it. Resident 67’s record showed diagnoses including COPD, major depressive disorder, and chronic kidney disease, and the resident’s care plan and order summary included a regular texture, thin liquids, fortified, lactose-free diet with extra gravy/sauce ordered. The report also found that CK 2 and the Dietary Supervisor could not verbalize substitute fortified food items for cheese. During interview, CK 2 stated she was not sure what substitute fortified items could be used if residents could not eat cheese and said she would use butter if residents were allergic to dairy products. The Dietary Supervisor stated he could not recall substitute food items for fortified diet instead of cheese and could not think of substitutes, although he acknowledged fortified diet was intended to add extra calories to prevent weight loss. Both staff members stated they should have known the substitutes because residents could be lactose intolerant or allergic to dairy products. Resident 67 stated she did not like cheese because it caused her stomach to hurt really bad and that she had received dairy products in the past and did not eat the meal. She also stated she could not understand why kitchen staff did not follow the meal ticket containing her likes and dislikes. The Registered Dietitian Nutritionist stated the meal ticket contained the resident’s preferences, allergies, diet order, and preferred dining location, and staff should have read and followed it to avoid giving food items that might cause adverse health effects or dishonoring the resident’s preference. The facility’s competency documentation for CK 1 and CK 2 did not specifically address follow-through of the meal ticket or the list of fortified food item substitutes.
Penalty
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Insufficient dietary staffing led to delayed lunch service when a food service aide left mid-shift and quit, leaving the kitchen short-handed and the dish area in disarray. The DON stated evening staff had to be called in early, and residents were served sandwiches instead of the scheduled meal around 2:00-2:30 PM rather than at the planned noon lunch time.
Insufficient dietary staffing resulted in delayed supper service and improvised meal substitutions when the pm cook did not report. Residents reported late meals, sandwiches served before pizza arrived, and difficulty with the food provided. Staff interviews and labor records showed repeated pm cook coverage problems, with the DM, DON, and corporate staff involved in arranging emergency food service and alternate diet meals after the scheduled cook failed to work.
Kitchen staff were not routinely trained or competency checked before performing duties, and dietary employees were observed using improper hand hygiene and cross-contamination practices. A dietary aide from a sister facility was allowed to dishwash without facility training or competency verification and threw meal tickets containing PHI into the trash. Another dietary aide dipped hands into a sanitizer bucket instead of washing at the sink, and a third staff member handled clean pans after wiping counters without washing hands.
Meals Served Late in Dining Rooms: Meal service did not begin on time in the 100 Avenue and 400 Avenue dining rooms based on the facility’s posted meal schedule. Observations showed breakfast and lunch were repeatedly delayed, with the last residents not served until well after the scheduled times. MA-J stated they could not both care for residents and deliver meals, so kitchen staff usually did it, and the DM confirmed dietary aides were also responsible for serving residents and that the meals were late.
Two kitchen employees were observed with unsafe food handling practices, including improper hand hygiene between glove changes, contact with contaminated surfaces, and cross contamination during prep. The cook also failed to follow menu and recipe directions for pureed foods and portion sizes, and took tray line temperatures incorrectly by placing the thermometer against the container instead of into the food.
Expired Food Handler Permit for Dietary Aide: The facility failed to ensure a dietary aide had a current food handler permit. Record review showed the aide’s certificate had expired, and the aide stated she was not aware it had expired. The Dietary Manager said she was responsible for tracking the 2-year training requirement but overlooked the expiration date, and the Administrator stated dietary staff were expected to have certificates before they expired.
Insufficient Dietary Staffing Caused Late Lunch Service
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out food and nutrition services, and lunch service on 07/17/26 was not completed on time. The Director of Food & Nutrition Services stated she was out sick that day and received calls that Food Service Manager E and Food Service Assistant F were not getting along. She reported that Food Service Assistant F clocked out and left in the middle of serving lunch and then walked out of the building and quit, which led her to call evening staff in early to serve lunch. The Director of Food & Nutrition Services stated residents were served lunch around 2:00 PM and were given ham and cheese sandwiches instead of the scheduled meal. Food Service Manager C stated he and Food Services Assistant D were called in early because lunch had not been prepared by the morning shift, and they made peanut butter and jelly sandwiches and ham and cheese sandwiches for residents. He stated lunch was supposed to be served at 12:00 PM but was served around 2:00 to 2:30 PM. Food Service Assistant D stated another aide walked out during lunch, left the dish area a mess, and residents received ham and cheese and peanut butter sandwiches late. A grievance dated 07/20/26 reflected residents in general complained about food service, and Food Service Assistant F’s HR statement described concerns about harassment and bullying in the work environment.
Insufficient dietary staffing led to delayed and improvised supper service
Penalty
Summary
The facility failed to ensure sufficient dietary staff were available to prepare and serve meals in accordance with the planned menu and residents’ physician-ordered diets. The deficiency involved 5 of 5 residents interviewed about food service, including residents on regular, renal, minced and moist, and consistent carbohydrate diets. The facility’s diet type report showed these residents had ordered diets that required different textures and/or restrictions, but the events described showed the evening meal was not reliably prepared or served as planned when the pm cook was absent. Residents reported that supper was delayed or not provided as expected when there was no pm cook. One resident stated supper arrived after 8:00 p.m. and that the facility ordered pizza late in the evening. Another resident stated supper was late and that the pizza soup provided was not good and could not be eaten. A third resident stated residents were given either one-half of a ham and cheese sandwich or a peanut butter and jelly sandwich around 7:00 p.m., then pizza was ordered later, with the meal not served until about 9:00 p.m. Another resident stated residents did not receive supper until an hour or more after it was due and that one-half of a sandwich was distributed before pizza arrived. One resident stated there had been a similar incident shortly after admission when there had not been a cook for the evening shift. Staff interviews and records showed repeated problems with pm cook coverage. A cook stated there had been no pm cook on the affected day, that she left when her shift ended, and that another scheduled cook had told her he could not work. The dietary aide stated he prepared sandwiches and fruit for residents, and the dietary regional director later came to the facility and brought pizza. The dietary manager stated he completed the schedules, used corporate float staff when available, and that nursing staff could contact him or the administrator if dietary staff did not report. He also stated the day had been a bad situation because neither he nor the administrator was available when both scheduled pm cooks did not report. Timecards and labor reports reviewed by surveyors showed instances where the pm cook was scheduled but worked only briefly, arrived late, or was not scheduled at all. The dietary regional director stated she was contacted about the lack of pm cook coverage, ordered and brought pizza, and prepared alternate diet meals, including pureed pizza with applesauce and pudding or a sandwich with diced peaches for residents requiring alternate diets. The dietitian stated the facility should have followed the planned menus and had a written plan of action for when a pm cook did not report.
Kitchen Staff Training and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills. During dishwashing observations, Dietary Aide 3 from a sister facility was seen throwing leftover food, plastic, and meal tickets into the trash while working in the dishmachine area. The Dietary Supervisor stated Dietary Aide 3 came from the sister facility, had not been trained before starting work in the facility, and had not had his competency evaluated before being allowed to dishwash. The Dietary Supervisor also stated the meal tickets contained resident names, room numbers, diet orders, allergies, medical record numbers, and pictures, and that they should have been shredded before disposal because they contained PHI. The Dietary Supervisor, Administrator, Director of Nursing, and Director of Staff Development each stated that staff from the sister facility could be shared, but also stated that training, credential review, and competency verification were expected before an employee started working in the kitchen. The Director of Staff Development stated she was not aware the sister facility was bringing an employee into the facility and did not provide handwashing or HIPAA training to Dietary Aide 3. The DON stated there was no signed job description, competency, or training completed for Dietary Aide 3 before he worked in the kitchen. The facility also failed to ensure dietary staff understood hand hygiene and clean-versus-dirty work practices. Dietary Aide 2 was observed dipping his hands into a sanitizer bucket while working in the dishwashing area and then putting away clean dishes. He stated he did so because a coworker told him to, but he did not know why. The Dietary Supervisor stated the sanitizer bucket was for cleaning surfaces and carts, not hands, and that handwashing should be done at the sink to prevent cross-contamination. In a separate observation, [NAME] 2 wiped countertops with a blue towel and then put away clean pots and pans without washing her hands. [NAME] 2 stated she had been taught to wash hands when touching dirty items and believed it was acceptable not to wash because the towel and surfaces were clean. The Dietary Supervisor stated she needed to wash her hands to prevent cross-contamination, and the Infection Preventionist stated dietary staff should wash hands when moving from dirty to clean areas and before handling food or clean equipment.
Meals Served Late in Dining Rooms
Penalty
Summary
The facility failed to serve meals in a timely manner based on its posted meal times, affecting residents who ate in the dining rooms. The posted schedule listed breakfast at 7:30 AM, lunch at 11:30 AM, and the evening meal at 5:30 PM, with dining room locations identified as 100 Avenue and 400 Avenue. During observations, meal service in the 100 Avenue dining room had not started at 11:57 AM on 7/13/26, and the last resident was not served lunch until 12:45 PM. On 7/14/26, breakfast had not started in the 100 Avenue dining room at 8:00 AM, and meal service had not started in the 400 Avenue dining room at 8:10 AM. Further observations showed breakfast in the 400 Avenue dining room was not fully served until 8:55 AM on 7/14/26, and lunch in that dining room had not started at 11:50 AM and was not fully served until 12:48 PM. On 7/15/26, breakfast was not fully served until 8:35 AM in the 400 Avenue dining room and 8:37 AM in the 100 Avenue dining room. MA-J stated on 7/14/26 that they were responsible for delivering meals but could not care for residents and deliver meals at the same time, so kitchen staff typically did this and it took longer than anticipated. The Dietary Manager confirmed that the dietary aides who serve meals were also responsible for serving residents and acknowledged the listed meals were late being served.
Unsafe Kitchen Food Handling and Tray Line Practices
Penalty
Summary
The facility failed to ensure that two of 19 kitchen employees demonstrated the competency and skills needed to safely perform daily kitchen duties. During observations in the kitchen and on the tray line, improper hand hygiene was observed, cross contamination occurred during food preparation, resident menus and recipes were not followed, and food temperatures were not properly taken for tray line service. The cook was observed removing gloves and putting on new gloves multiple times without washing hands between glove changes. The dietary aide was also observed removing gloves, touching the trash can, and then putting on new gloves without washing hands. Facility policies required hand washing before applying gloves, before donning a new pair, and after touching contaminated surfaces or items. During food preparation, the cook was observed working on an unclean, cluttered countertop with food crumbs present, returning cooked meat to the cutting board after touching a portion guide on the wall, flipping the cutting board after it had contacted the soiled countertop, returning from the dish machine to the food preparation area without washing hands, folding aluminum foil against clothing before using it to cover vegetables, and touching scale controls before handling cooked zucchini with the same gloved hand. During tray line, the cook was also observed touching his face and continuing to serve food without changing gloves or performing hand hygiene. The cook did not follow menu and recipe directions for pureed foods and portioning. Pureed Italian chicken and pureed zucchini were prepared with broth that was not low-sodium, and broth was added in an unmeasured amount or before blending rather than following the recipe directions. The regular diet baked zucchini was supposed to be served as a 1/2 cup portion using a #8 scoop, but the cook served it using a 1/3 cup #12 scoop instead. The cook was also observed taking a food temperature with the thermometer probe touching the hot bottom and side of the food container rather than being placed in the food.
Expired Food Handler Permit for Dietary Aide
Penalty
Summary
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service was not met when the facility failed to ensure Dietary Aide B had a current food handler permit. Record review of the food handler certificates provided by the facility showed that Dietary Aide B’s food handler certificate expired on 07/15/25. During an interview, Dietary Aide B stated she was not aware her food handler permit had expired and stated it was important to have a food handler certificate to know how to handle food and prevent cross contamination or infection. During an interview, the Dietary Manager stated she was responsible for ensuring staff completed their food handler certificate training every 2 years and that she reviewed the certificates weekly but overlooked the actual day it expired. The Dietary Manager stated this failure could potentially put residents at risk for food borne illness and cross contamination. The Administrator stated she expected the Dietary Manager to ensure dietary staff had their food handler certificates before they expired and stated this failure could potentially put residents at risk for food borne illness and cross contamination. The facility policy titled Certified Food Protection Professional and Food Safety Training stated the food establishment shall maintain on premises a certificate of completion of the food handlers training course for each employee.
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