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Based on observation, record review, and staff interviews, the facility failed to ensure that frozen foods were stored frozen solid until ready for use to prevent the risk of foodborne illness in a highly vulnerable population. This failure occurred for frozen raw meats and food items that were stored for use to prepare meals for 37 of 60 patients receiving oral nutrition from October 8-13, 2017. The failure was evidenced by the presence of thawed meats such as fish and beef, with puddles of (red colored substance, resembling blood) juices dripping onto the freezer floor. The internal freezer temperature was observed at 40 degrees Fahrenheit.

An Immediate Jeopardy (IJ) was identified at 6:20 PM on Thursday, October 12, 2017 under 42 CFR§ 482.28 Food and Dietetic Services; A-0618, Dietetic services must be organized and directed in accordance with accepted standards of practice. On Thursday, October 12, 2017 at 8:08 PM, the facility's Administrator provided a letter documenting a corrective action plan to include staff education, policy/procedure modifications for food handling and freezer/refrigeration monitoring. On October 16, 2017, at 8:30 PM, the Immediate Jeopardy was removed after the facility's administrative team provided sufficient evidence to reflect staff education and confirmation of staff competency regarding the corrective measures.

The findings include:

During the initial tour of the kitchen on 10/12/2017 at 9:10 AM, the surveyor observed the facility's only freezer internal temperature at 40 degrees Fahrenheit. The external freezer thermometer reading was 36 degrees Fahrenheit, a four (4) degrees difference from the internal temperature observed at 9:10 AM. The freezer contained large volumes of raw meats and food items in a thawed state (not frozen solid to touch).

The food items stored in the freezer at the time of the observation included large vacuum-sealed beef portions, chicken, large vacuum-sealed pork portions, ricotta cheese, fish, Lo Mein noodles, and seafood products such as shrimp. The food items physically inspected by touch were found to be soft allowing an approximately one (1) inch indention when pressure was applied. Also, boxed item's outer surfaces were moist and damp. Meats packaged in vacuum-sealed coverings were moist and a red substance (resembling blood) was noted dripping from the meats directly onto the floor beneath the storage rack. The food items were stacked on top of one another preventing the flow of air around the frozen food items in a thawing state. The raw meats were not stored separately in a drip-proof container.

Record review of the facility's temperature monitoring tool titled, "Nutrition Freezer Temperature Log," dated October 2017 with data from October 1 through 11, 2017, showed the facility's staff recorded freezer temperatures greater than zero degrees as follows:

a. October 1, 2017: three (3) degrees Fahrenheit (ºF) in the morning and two (2) ºF in the afternoon

b. October 4, 2017: one (1) ºF in the afternoon (no morning temperature documented)

c. October 5, 2017: one (1) ºF in the morning

d. October 6, 2017: one (1) ºF in the afternoon.

e. October 8, 2017: three (3) ºF in the morning and one (1) ºF in the afternoon

f. October 9, 2017: three (3) ºF in the morning and afternoon

g. October 10, 2017: 28 ºF in the afternoon (no morning temperature documented)

h. October 11, 2017: Negative two (-2) ºF in the afternoon (no morning temperature documented)

The facility's "Nutrition Freezer Temperature Log" identified the acceptable freezer temperature range of zero to - (minus)10 degrees ºF. The area reserved for the facility's staff to document the corrective actions taken when temperatures are out of range was left blank except for October 8, 9, and 11, 2017, which indicated "Engineering was notified."

The freezer temperature monitoring tool does not contain any information related to the status of the frozen foods (i.e., firmness of meat and food items) on the dates and times, when the freezer temperatures were documented greater than zero degrees Fahrenheit.

During an interview on October 12, 2017, at approximately10:30 AM, Employee #7, Food Service Manager, stated, he was not aware that the freezer was not working as intended before the discovery during the initial kitchen tour. Employee #7 stated that the dietary staff monitors and records the freezer temperatures twice daily; once in the morning and once in the afternoon; however, no specific time/hour is specified. The morning shift's tour of duty is 6:30 AM to 3:00 PM and the afternoon shift's tour of duty is 11:30 AM to 8:00 PM. An exact time the freezer temperatures were checked was not recorded. When asked about the timeline for the incident, Employee # 7 indicated that further information gathering was needed to adequately answer questions surrounding the freezer malfunction and status of food temperatures.

At approximately 2:30 PM on October 12, 2017, during the follow-up telephone conference with the facility's administrative team to include Employee #7, he stated the facility's dietary staff identified an issue with the freezer (temperature: 3 ºF) on October 8, 2017, for which the executive chef notified Plant Operations. On October 9, 2017, a preventative maintenance service vendor was contacted to evaluate the freezer. The preventative maintenance vendor provided recommendations for needed freezer repairs. The vendor did not perform recommended repairs during the October 9, 2017, service call. On the afternoon of October 10, 2017, the freezer temperature was documented as 28 ºF. The facility staff placed a call to a second freezer repair vendor for concerns regarding the freezer temperatures. The vendor performed some repairs.

When asked direct questions regarding the monitoring and storage of the frozen foods, Employee #7 stated that the food items located in the freezer were acceptable for use since the freezer temperatures did not rise above 41 ºF. According to Employee #7, the foods were in a "thawing" state and under refrigeration since the temperature in the malfunctioning freezer was below 41 ºF. Employee # 7 stated the facility did not check the temperature of the food nor did they monitor the frozen food for firmness. Employee #7 further stated that it would take approximately five (5) days for the large portions of meats to thaw in the refrigerator. Regarding the raw meats and food items observed thawed, he was unable to explain how long the raw meats were maintained without proper freezing temperatures to cause the level of thawing noted.

Employee # 10, Infection Preventionist, was present during the telephone conference on October 12, 2017, at approximately 2:30 PM. When asked about the facility's policy for frozen raw foods which are no longer frozen solid, Employee # 10 stated that the facility is expected to discard frozen raw food items that are no longer frozen solid for more than "12 to 16 hours." In addition, Employee # 10 stated that while the freezer repairs were being performed on October 10, 2017, the foods were removed from the freezer. However, the facility was unable to provide insight as to where the frozen raw meats and food items were stored during the repairs. Employee #10 further stated that the facility would discard the thawed raw meats and food items located in the malfunctioning freezer.

The facility was unable to provide insight or explanation for the raw meat products and food items stored on the wire shelving in the freezer with (red colored, resembling blood) juices dripping onto the floor and moisture saturated cardboard boxes containing raw meats. The administrative team to include the Administrator, Director of Nursing, Infection Preventionist and Food Service Manager acknowledged not being aware of the status of raw foods stored in the freezer, which placed patients at potential risk for food-borne illness.

Furthermore, the facility failed to establish policies and procedures to govern the facility's practice for monitoring frozen food firmness, in the absence of a properly functioning freezer, to ensure frozen foods remained frozen solid to prevent the risk of foodborne illness. The facility was aware of the failed practice which created the potential for harm related to unsafe food storage practices, potentially exposing patients to foodborne pathogens.

On October 12, 2017 6:20 PM, the State Agency notified the facility of the Immediate Jeopardy (IJ). At 8:08 PM on October 12, 2017, the facility submitted a corrective action plan and verbalized that none of the food items stored in the freezer would be used for patient consumption.

October 16, 2017, at 8:30 PM, the Immediate Jeopardy was removed after the facility's administrative team provided sufficient evidence to reflect staff education and confirmation of staff competency regarding the corrective measures, including but not limited to staff education, policy/procedure modifications and enhanced freezer monitoring procedures.
Cross reference 42 CFR 482.28(a)(1)(ii)

Based on observation, record review, and staff interviews, the facility failed to ensure that the facility's only freezer was operational to ensure that frozen foods were kept frozen solid until ready for the cooking process. The failed practice impacted raw meats and food items intended for use to prepare meals for 37 of 60 patients receiving oral nutrition from October 8 through 13, 2017.

An Immediate Jeopardy (IJ) was identified at 6:20 PM on Thursday, October 12, 2017 under 42CFR§482.41; A-0700 Physical Environment; failure to maintain equipment (freezer) in safe operating condition.

On Thursday, October 12, 2017 at 8:08 PM, the facility's Administrator provided a letter documenting a corrective action plan to include staff education, policy/procedure modifications for food handling and freezer/refrigeration monitoring. On October 16, 2017, at 8:30 PM, the Immediate Jeopardy was removed after the facility's administrative team provided sufficient evidence to reflect staff education and confirmation of staff competency regarding the corrective measures.

The findings include:

During the initial tour of the kitchen on 10/12/2017 at 9:10 AM, the surveyor observed the facility's only freezer internal temperature at 40 degrees Fahrenheit. The external freezer thermometer reading was 36 degrees Fahrenheit, a four (4) degrees difference from the internal temperature observed at 9:10 AM. The freezer contained large volumes of raw meats and food items in a thawed state (not frozen solid to touch).

Record review of the facility's temperature monitoring tool titled, "Nutrition Freezer Temperature Log," dated October 2017 with data from October 1 through 11, 2017, showed the facility's staff recorded freezer temperatures greater than zero degrees as follows:

a. October 1, 2017: three (3) degrees Fahrenheit (ºF) in the morning and two (2) ºF in the afternoon

b. October 4, 2017: one (1) ºF in the afternoon (no morning temperature documented)

c. October 5, 2017: one (1) ºF in the morning

d. October 6, 2017: one (1) ºF in the afternoon

e. October 8, 2017: three (3) ºF in the morning and one (1) ºF in the afternoon

f. October 9, 2017: three (3) ºF in the morning and afternoon

g. October 10, 2017: 28 ºF in the afternoon (no morning temperature documented)

h. October 11, 2017: Negative two (-2) ºF in the afternoon (no morning temperature documented)

The facility's "Nutrition Freezer Temperature Log" identified the acceptable freezer temperature range of zero to -10 degrees ºF. The area reserved for the facility's staff to document the corrective action to address the actions taken when temperatures are out of range was left blank except for October 8, 9, and 11, 2017, which indicated "Engineering was notified."

The freezer temperature monitoring tool does not contain any information related to the status of the frozen foods (i.e., firmness of meat and food items) on the dates and times, when the freezer temperatures were documented greater than zero degrees Fahrenheit.

During an interview on October 12, 2017, at approximately10:30 AM, Employee #7, Food Service Manager, stated, he was not aware that the freezer was not working as intended before the discovery during the initial kitchen tour. Employee #7 stated that the dietary staff monitors and records the freezer temperatures twice daily; once in the morning and once in the afternoon; however, no specific time/hour is specified. The morning shift's tour of duty is 6:30 AM to 3:00 PM and the afternoon shift's tour of duty is 11:30 AM to 8:00 PM. An exact time the freezer temperatures were checked was not recorded. When asked about the timeline for the incident, Employee # 7 indicated that further information gathering was needed to adequately answer questions surrounding the freezer malfunction and status of food temperatures.

At approximately 2:30 PM on October 12, 2017, during the follow-up telephone conference with the facility's administrative team to include Employee #7, he stated the facility's dietary staff identified an issue with the freezer (temperature: 3 ºF) on October 8, 2017, for which the executive chef notified Plant Operations about the freezer temperature. On October 9, 2017, a preventative maintenance service vendor was contacted to evaluate the freezer. The preventative maintenance vendor provided a recommendation for needed freezer repairs. The vendor did not perform recommended repairs during the October 9, 2017, service call. On the afternoon of October 10, 2017, the freezer temperature was documented as 28 ºF. The facility staff placed a call to a second freezer repair vendor for concerns regarding the freezer temperatures. The vendor performed some repairs.

According to the "Maintenance Order" from the [Preventative Maintenance Vendor] dated October 9, 2017at 8:30 AM, the work requested included a check of the walk-in freezer. The discharge temperature was "very high" and the refrigerant needed to be changed. The document does not show that the recommended work was completed on October 9, 2017.

On October 10, 2017, at 2:45 PM, another freezer repair vendor serviced the walk-in freezer. The "Invoice" documented repairs completed. The repairs included the replacement of a transducer, and the freezer was turned back on. According to the invoice, "the box came down in temp."

During a telephonic interview on October 12, 2017, at approximately 2:30 PM, Employee #11, Plant Operations Manager, was questioned about the procedures taken to address the malfunctioning freezer. Employee # 11 stated that when notified of "out of range" freezer temperatures, the engineering department's staff places a call to an outside vendor for repairs. Freezer temperatures are not checked by engineering to confirm accuracy of information reported by the dietary staff. Clarification was requested from Employee #11 to explain the documentation from the repair vendor on October 10, 2017; which stated "the box came down in temp." He could not provide further insight into the meaning of the vendor's note neither could he demonstrate that the freezer temperature was checked by the vendor or the facility after the repairs.

Furthermore, the engineering department did not notify administration of the walk-in freezer's failure to maintain raw meats and food items in a solid state. The walk-in freezer temperature was noted to be out of range on 11 out 24 observations. The failure to ensure the walk-in freezer operated, as intended, placed the raw meats and food items at risk of growing bacteria that causes foodborne illnesses when ingested.

On October 12, 2017 6:20 PM, the State Agency notified the facility of the Immediate Jeopardy (IJ). At 8:08 PM on October 12, 2017, the facility submitted a corrective action plan and verbalized that none of the food items stored in the freezer would be used for patient consumption.

October 16, 2017, at 8:30 PM, the Immediate Jeopardy was removed after the facility's administrative team provided sufficient evidence to reflect staff education and confirmation of staff competency regarding the corrective measures, including but not limited to staff education, policy/procedure modifications and enhanced freezer monitoring procedures.
Cross reference 42 CFR 482.41(a), A-701

Based on observation, record review, and staff interviews, it was determined the food services director failed to ensure safe practices for food handling as evidenced by a failure to ensure that frozen foods were stored frozen solid until ready for use to prevent the risk of foodborne illness in a highly vulnerable population. This failure occurred for frozen raw meats and food items that were stored for use to prepare meals for 37 of 60 patients receiving oral nutrition from October 8-13, 2017. The failure was evidenced by the presence of thawed meats such as fish and beef, with puddles of (red colored substance, resembling blood) juices dripping onto the freezer floor. The internal freezer temperature was observed at 40 degrees Fahrenheit.

The findings include:

During the initial tour of the kitchen on 10/12/2017 at 9:10 AM, the surveyor observed the facility's only freezer internal temperature at 40 degrees Fahrenheit. The external freezer thermometer reading was 36 degrees Fahrenheit, a four (4) degrees difference from the internal temperature observed at 9:10 AM. The freezer contained large volumes of raw meats and food items in a thawed state (not frozen solid to touch).

The food items stored in the freezer at the time of the observation included large vacuum-sealed beef portions, chicken, large vacuum-sealed pork portions, ricotta cheese, fish, Lo Mein noodles, and seafood products such as shrimp. The food items physically inspected by touch were found to be soft allowing an approximately one (1) inch indention when pressure was applied. Also, boxed item's outer surfaces were moist and damp. Meats packaged in vacuum-sealed coverings were moist and a red substance (resembling blood) was noted dripping from the meats directly onto the floor beneath the storage rack. The food items were stacked on top of one another preventing the flow of air around the frozen food items in a thawing state. The raw meats were not stored separately in a drip-proof container.

Record review of the facility's temperature monitoring tool titled, "Nutrition Freezer Temperature Log," dated October 2017 with data from October 1 through 11, 2017, showed the facility's staff recorded freezer temperatures greater than zero degrees as follows:

a. October 1, 2017: three (3) degrees Fahrenheit (ºF) in the morning and two (2) ºF in the afternoon

b. October 4, 2017: one (1) ºF in the afternoon (no morning temperature documented)

c. October 5, 2017: one (1) ºF in the morning

d. October 6, 2017: one (1) ºF in the afternoon.

e. October 8, 2017: three (3) ºF in the morning and one (1) ºF in the afternoon

f. October 9, 2017: three (3) ºF in the morning and afternoon

g. October 10, 2017: 28 ºF in the afternoon (no morning temperature documented)

h. October 11, 2017: Negative two (-2) ºF in the afternoon (no morning temperature documented)

The facility's "Nutrition Freezer Temperature Log" identified the acceptable freezer temperature range of zero to - (minus)10 degrees ºF. The area reserved for the facility's staff to document the corrective actions taken when temperatures are out of range was left blank except for October 8, 9, and 11, 2017, which indicated "Engineering was notified."

The freezer temperature monitoring tool does not contain any information related to the status of the frozen foods (i.e., firmness of meat and food items) on the dates and times, when the freezer temperatures were documented greater than zero degrees Fahrenheit.

During an interview on October 12, 2017, at approximately10:30 AM, Employee #7, Food Service Manager, stated, he was not aware that the freezer was not working as intended before the discovery during the initial kitchen tour. Employee #7 stated that the dietary staff monitors and records the freezer temperatures twice daily; once in the morning and once in the afternoon; however, no specific time/hour is specified. The morning shift's tour of duty is 6:30 AM to 3:00 PM and the afternoon shift's tour of duty is 11:30 AM to 8:00 PM. An exact time the freezer temperatures were checked was not recorded. When asked about the timeline for the incident, Employee # 7 indicated that further information gathering was needed to adequately answer questions surrounding the freezer malfunction and status of food temperatures.

At approximately 2:30 PM on October 12, 2017, during the follow-up telephone conference with the facility's administrative team to include Employee #7, he stated the facility's dietary staff identified an issue with the freezer (temperature: 3 ºF) on October 8, 2017, for which the executive chef notified Plant Operations. On October 9, 2017, a preventative maintenance service vendor was contacted to evaluate the freezer. The preventative maintenance vendor provided recommendations for needed freezer repairs. The vendor did not perform recommended repairs during the October 9, 2017, service call. On the afternoon of October 10, 2017, the freezer temperature was documented as 28 ºF. The facility staff placed a call to a second freezer repair vendor for concerns regarding the freezer temperatures. The vendor performed some repairs.

When asked direct questions regarding the monitoring and storage of the frozen foods, Employee #7 stated that the food items located in the freezer were acceptable for use since the freezer temperatures did not rise above 41 ºF. According to Employee #7, the foods were in a "thawing" state and under refrigeration since the temperature in the malfunctioning freezer was below 41 ºF. Employee # 7 stated the facility did not check the temperature of the food nor did they monitor the frozen food for firmness. Employee #7 further stated that it would take approximately five (5) days for the large portions of meats to thaw in the refrigerator. Regarding the raw meats and food items observed thawed, he was unable to explain how long the raw meats were maintained without proper freezing temperatures to cause the level of thawing noted.

Employee # 10, Infection Preventionist, was present during the telephone conference on October 12, 2017, at approximately 2:30 PM. When asked about the facility's policy for frozen raw foods which are no longer frozen solid, Employee # 10 stated that the facility is expected to discard frozen raw food items that are no longer frozen solid for more than "12 to 16 hours." In addition, Employee # 10 stated that while the freezer repairs were being performed on October 10, 2017, the foods were removed from the freezer. However, the facility was unable to provide insight as to where the frozen raw meats and food items were stored during the repairs. Employee #10 further stated that the facility would discard the thawed raw meats and food items located in the malfunctioning freezer.

The facility was unable to provide insight or explanation for the raw meat products and food items stored on the wire shelving in the freezer with (red colored, resembling blood) juices dripping onto the floor and moisture saturated cardboard boxes containing raw meats. The administrative team to include the Administrator, Director of Nursing, Infection Preventionist and Food Service Manager acknowledged not being aware of the status of raw foods stored in the freezer, which placed patients at potential risk for food-borne illness.

Furthermore, the facility failed to establish policies and procedures to govern the facility's practice for monitoring frozen food firmness, in the absence of a properly functioning freezer, to ensure frozen foods remained frozen solid to prevent the risk of foodborne illness. The facility was aware of the failed practice which created the potential for harm related to unsafe food storage practices, with the potential to expose patients to foodborne pathogens.

Cross referenced to 42 CFR §482.28 A618

Based on observation, record review, and staff interviews, the facility failed to ensure that the facility's only freezer was maintained in a manner that the safety and well-being of patients was assured, as evidenced by the failure of the freezer to function as intended in order to maintain frozen foods in a solid frozen state until ready for the cooking process. The failed practice impacted raw meats and food items intended for use to prepare meals for 37 of 60 patients receiving oral nutrition from October 8 through 13, 2017.

The findings include:

During the initial tour of the kitchen on 10/12/2017 at 9:10 AM, the surveyor observed the facility's only freezer internal temperature at 40 degrees Fahrenheit. The external freezer thermometer reading was 36 degrees Fahrenheit, a four (4) degrees difference from the internal temperature observed at 9:10 AM. The freezer contained large volumes of raw meats and food items in a thawed state (not frozen solid to touch).


Record review of the facility's temperature monitoring tool titled, "Nutrition Freezer Temperature Log," dated October 2017 with data from October 1 through 11, 2017, showed the facility's staff recorded freezer temperatures greater than zero degrees as follows:

a. October 1, 2017: three (3) degrees Fahrenheit (ºF) in the morning and two (2) ºF in the afternoon

b. October 4, 2017: one (1) ºF in the afternoon (no morning temperature documented)

c. October 5, 2017: one (1) ºF in the morning

d. October 6, 2017: one (1) ºF in the afternoon

e. October 8, 2017: three (3) ºF in the morning and one (1) ºF in the afternoon

f. October 9, 2017: three (3) ºF in the morning and afternoon

g. October 10, 2017: 28 ºF in the afternoon (no morning temperature documented)

h. October 11, 2017: Negative two (-2) ºF in the afternoon (no morning temperature documented)

The facility's "Nutrition Freezer Temperature Log" identified the acceptable freezer temperature range of zero to -10 degrees ºF. The area reserved for the facility's staff to document the corrective action to address the actions taken when temperatures are out of range was left blank except for October 8, 9, and 11, 2017, which indicated "Engineering was notified."

The freezer temperature monitoring tool does not contain any information related to the status of the frozen foods (i.e., firmness of meat and food items) on the dates and times, when the freezer temperatures were documented greater than zero degrees Fahrenheit.

During an interview on October 12, 2017, at approximately10:30 AM, Employee #7, Food Service Manager, stated, he was not aware that the freezer was not working as intended before the discovery during the initial kitchen tour. Employee #7 stated that the dietary staff monitors and records the freezer temperatures twice daily; once in the morning and once in the afternoon; however, no specific time/hour is specified. The morning shift's tour of duty is 6:30 AM to 3:00 PM and the afternoon shift's tour of duty is 11:30 AM to 8:00 PM. An exact time the freezer temperatures were checked was not recorded. When asked about the timeline for the incident, Employee # 7 indicated that further information gathering was needed to adequately answer questions surrounding the freezer malfunction and status of food temperatures.

At approximately 2:30 PM on October 12, 2017, during the follow-up telephone conference with the facility's administrative team to include Employee #7, he stated the facility's dietary staff identified an issue with the freezer (temperature: 3 ºF) on October 8, 2017, for which the executive chef notified Plant Operations about the freezer temperature. On October 9, 2017, a preventative maintenance service vendor was contacted to evaluate the freezer. The preventative maintenance vendor provided a recommendation for needed freezer repairs. The vendor did not perform recommended repairs during the October 9, 2017, service call. On the afternoon of October 10, 2017, the freezer temperature was documented as 28 ºF. The facility staff placed a call to a second freezer repair vendor for concerns regarding the freezer temperatures. The vendor performed some repairs.

According to the "Maintenance Order" from the [Preventative Maintenance Vendor] dated October 9, 2017at 8:30 AM, the work requested included a check of the walk-in freezer. The discharge temperature was "very high" and the refrigerant needed to be charged. The document does not show that the recommended work was completed on October 9, 2017.

On October 10, 2017, at 2:45 PM, another freezer repair vendor serviced the walk-in freezer. The "Invoice" documented repairs completed. The repairs included the replacement of a transducer, and the freezer was turned back on. According to the invoice, "the box came down in temp."

During a telephonic interview on October 12, 2017, at approximately 2:30 PM, Employee #11, Plant Operations Manager, was questioned about the procedures taken to address the malfunctioning freezer. Employee # 11 stated that when notified of "out of range" freezer temperatures, the engineering department's staff places a call to an outside vendor for repairs. Freezer temperatures are not checked by engineering to confirm accuracy of information reported by the dietary staff. Clarification was requested from Employee #11 to explain the documentation from the repair vendor on October 10, 2017; which stated "the box came down in temp." He could not provide further insight into the meaning of the vendor's note neither could he demonstrate that the freezer temperature was checked by the vendor or the facility after the repairs.

Furthermore, the engineering department did not notify administration of the walk-in freezer's failure to maintain raw meats and food items in a solid state. The walk-in freezer temperature was noted to be out of range on 11 out 24 observations. The failure to ensure the walk-in freezer operated, as intended, placed the raw meats and food items at risk of growing bacteria that causes foodborne illnesses when ingested.

Cross reference 42 CFR §482.41, A-700