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
Resources
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Dish Machine Chlorine Test Strips Misread by Dietary Staff: Dietary staff were observed and interviewed while checking chlorine in the dish machine, and both DAs stated they estimated strip readings instead of interpreting the color chart correctly. The Dish Machine Temperature Log showed several recorded ppm values that did not match the chart, and the DS stated staff had been told to read the strips by estimating. The facility P&P required chlorine to read 50-100 ppm on the dish surface in the final rinse.
Food service staff lacked current food handler certification when two kitchen staff were observed preparing lunch meals and record review showed one expired certificate and one missing certificate. Interviews confirmed one staff member did not have a current certificate and another learned her certificate had expired, while the MTD was assisting in the kitchen after the prior dietary manager was terminated.
Dishwasher Sanitization Temperatures Not Understood by Kitchen Staff: Kitchen staff did not know the required high-temp dishmachine settings for sanitization. During observation, the wash cycle reached 150°F and the rinse cycle reached 171°F, while the staff member operating the machine stated those were normal and sufficient to sanitize dishes. The DM and RD later stated the wash cycle needed to reach 160°F and the rinse cycle at least 180°F, and the facility policy listed the same temperatures.
Expired Food Handler Certificate for Dietary Aide: The facility failed to ensure a dietary aide maintained a current Food Handler Certificate. Record review showed the aide’s certificate had expired, and interviews with the DM, DON, and Administrator confirmed they were responsible for tracking staff certification status but had not noticed the expiration. The aide stated she did not realize the certificate had expired, and the facility policy required all employees who handle, prepare, or serve food to be trained in safe food handling and preventing foodborne illness.
Repeated dietary staffing shortages resulted in frequent dining room closures, missed meal service in the dining room, and resident complaints about food quality, incorrect menus, and the kitchen running out of items. Staff reported that cooks and dietary aides repeatedly called off or were not scheduled, several dietary workers were not replaced, and the Administrator said staffing decisions were made by a third-party vendor.
Insufficient dietary staffing delayed meal service and disrupted resident care. Dietary staff were still on the tray line during breakfast service, the last breakfast cart left the kitchen late, and lunch tray line preparation was repeatedly delayed with trays not ready until well after the scheduled time. Residents on the unit were still eating breakfast late in the morning, lunch trays were not delivered to the 400 hall until mid-afternoon, and CNAs reported meals were often so late that it affected when they could provide showers and other care.
Dish Machine Chlorine Test Strips Misread by Dietary Staff
Penalty
Summary
Food service staff were not competent in reading test strips used to check chlorine levels in the dishwashing machine. During a concurrent observation and interview, Dietary Aide 1 demonstrated how to test the final rinse water by dipping a strip and comparing it to the color chart, and stated the strip read 50 ppm with the kitchen following a 50-200 ppm chlorine range. However, review of the kitchen Dish Machine Temperature Log for 5/2026 showed multiple entries of 58, 59, 60, 68, 69, and 70 ppm on various breakfast and lunch dates. During interviews and record review, Dietary Aide 1 stated those readings were not correct interpretations because the chlorine color chart only showed a range of 50-100 ppm, and she had estimated the readings after being told to read them that way. Dietary Aide 2 stated she also approximated chlorine levels based on how the strip became darker or lighter and acknowledged she had not been reading the strips correctly. The Dietary Supervisor stated staff had been instructed to estimate the readings, and the facility policy for DishWashing stated chlorine should read 50-100 ppm on the dish surface in the final rinse.
Food Service Staff Lacked Current Food Handler Certification
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out food and nutrition services for two of four kitchen staff reviewed. Record review showed DTA C’s food handler certificate had expired on 08/25/2024, and there was no certificate available for [NAME] B. During observation on 05/20/2026, [NAME] B and DTA C were seen preparing lunch meals in the facility kitchen while the MTD was also present putting away food items. Interviews confirmed that [NAME] B did not have a current food handler’s certificate and stated her prior certificate had expired approximately 10 years earlier. DTA C initially stated she had a food handler’s certificate, but later stated she learned the certificate was expired and that she had completed an update that morning. The MTD stated he was assisting in the kitchen after the prior dietary manager was terminated and said he had a current food handler’s certificate on his phone, while the DON and Interim ADMIN acknowledged that dietary staff should be qualified and compliant with kitchen regulations.
Dishwasher Sanitization Temperatures Not Understood by Kitchen Staff
Penalty
Summary
The facility failed to ensure kitchen staff were knowledgeable of the dishwasher rinse temperature required for sanitization during an observation of the dishmachine. During the observation, the dishwasher wash cycle reached 150 degrees Fahrenheit and the rinse cycle reached 171 degrees Fahrenheit. The staff member operating the dishwasher stated it was a high-temperature sanitization machine, that the temperatures observed were the normal wash and rinse temperatures, and that they were sufficient to sanitize the dishes. The staff member also stated the dishwasher had been used several times before it was checked and should have been warmed up. During interviews, the Dietary Manager stated the dishwasher needed to reach 160 degrees Fahrenheit on the wash cycle and 180 degrees Fahrenheit on the rinse cycle to sanitize dishes, and the Registered Dietitian stated the rinse cycle had to reach at least 180 degrees Fahrenheit. The Registered Dietitian also stated there was an issue with the temperature gauges on the dishwasher and that the cook should have been aware of the required dishwasher temperatures for sanitization and had previously received training. The Executive Director provided the facility policy for the certified conveyor dishmachine, which listed operating temperatures of 160 degrees Fahrenheit for the wash cycle and 180 degrees Fahrenheit for the sanitizing rinse.
Expired Food Handler Certificate for Dietary Aide
Penalty
Summary
The facility failed to provide sufficient support personnel to safely and effectively carry out food and nutrition services because one dietary aide did not maintain a current Food Handler Certificate. Record review showed Dietary Aide C was hired on 10/01/23 and had a Texas Food Handler Certificate issued on 02/14/24 with an expiration date of 02/13/26. During interview, the Dietary Manager stated the certificate should be renewed every 2 years and acknowledged she had not paid attention to when the certificate would expire. She also stated that she and the Business Office Manager were responsible for ensuring dietary staff had their food handler certificates. During interview, Dietary Aide C said she did not realize her certificate had expired and said the Dietary Manager told her the day before that it had expired. She stated she knew the certificate was required but did not see the risk in not updating it because she knew what to do. The Dietary Manager, DON, and Administrator all acknowledged responsibility for maintaining current certificates, and the Administrator stated she was not aware the certificate had expired. Record review of the policy titled, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, stated that all employees who handle, prepare, or serve food will be trained in safe food handling and preventing foodborne illness and must demonstrate knowledge and competency before working with food or serving food to residents.
Dietary staffing shortages led to repeated dining room closures and service issues
Penalty
Summary
The facility failed to provide sufficient support personnel to safely and effectively carry out the food and nutrition service. Review of dietary staff schedules and staff interviews showed repeated kitchen staffing shortages and call-offs, including days with no morning cook scheduled and multiple morning and afternoon dietary aide call-offs between 04/26/26 and 05/21/26. The facility census was 107, and three residents were identified as receiving nothing by mouth. During the Resident Council meeting, multiple residents reported frequent closure of the dining room, the kitchen running out of food items, incorrect menus, and poor food quality, stating these concerns had been repeatedly reported without resolution. Staff interviews confirmed the dining room was closed a couple of times a week or most days at lunch and dinner because of dietary staffing shortages, that five dietary workers left in March 2026 and were not replaced, and that staffing cuts had been ordered by the regional team. The Administrator stated she did not determine dietary staffing hours because the department was contracted to a third-party vendor that made staffing decisions before notifying her.
Insufficient Dietary Staffing Caused Delayed Meal Service
Penalty
Summary
The facility failed to employ sufficient staff to safely and effectively carry out the functions of food and nutrition services. During the initial kitchen tour on 5/17/2026 at 9:05 AM, dietary staff were still on the tray line, and the dietary aide stated they were prepping cart #7 of 9 carts. At 9:25 AM, the aide said they were prepping the last cart, and the last tray cart did not leave the kitchen until 9:50 AM, although the aide stated the goal was to have the last cart out by 9:00 AM. The aide reported the normal staffing was three aides and one cook, and that this was the daily staffing pattern. The cook directed the surveyor to return at 11:30 AM to observe lunch tray line preparation. At 11:25 AM on 5/17/2026, three residents on the [NAME] unit were still eating breakfast and several others still had breakfast trays in their rooms. At 11:30 AM, four additional staff members were in the kitchen, but the tray line was not ready; the District Manager stated they needed 15 more minutes. At 12:05 PM, the tray line was still not ready, and it was not ready until 12:40 PM. The last cart was finished and loaded at 2:00 PM. On 5/18/2026 at 2:38 PM, residents on the 400 hall still did not have lunch trays, and the Administrator stated the trays were on a cart outside the kitchen door and had not been pushed up because staff were busy doing something else. The last tray on that cart was passed at 2:48 PM, leaving many residents on the unit still eating lunch after 3:00 PM. The Dining Services District Manager stated the goal was four aides and one cook per shift, but that this was rarely happening because there were not enough people, and the department had been short staffed since March. CNA #12 and CNA #8 also reported that meal service was often very late and interfered with showering and other care tasks.
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