§483.60(i) Food safety requirements.
The facility must -
§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.
§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
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Observations:
Based on observation, review of facility policies, and staff and resident interviews, it was determined that the facility ensure that refrigerated food items were timely discarded to ensure food safety.
Findings include:
Review of the facility's policy titled Food Quality and Palatability, dated February 2023, revealed that food is to be prepared using methods that conserve nutritional value, flavor, and appearance. The policy states that food must be palatable, visually appealing, and served at a safe and appetizing temperature. Additionally, food and liquids are to be prepared and served in a manner, form, and texture that meets the individual needs of residents.
Further review indicated that cooks are expected to prepare food in a sanitary manner, following the principles of Hazard Analysis Critical Control Point (HACCP) and adhering to time and temperature guidelines as outlined in the federal Food Code. Recipes are to be followed, and seasoning should reflect regional and ethnic preferences as appropriate.
Review of the Food Storage and Retention Guide from Health Care Service Group, incorporated into dietary operations in 2017, references the FDA Food Code 2013. It specifies that time/temperature control for safety (TCS) foods, including fruits and vegetables, may be stored for up to seven days. Day one is defined as the date of receipt into inventory, and items may be retained for one week or until visual spoilage is noted.
Observation during a kitchen tour conducted at 9:50 a.m. on September 23, 2025, revealed temperature log affixed to its exterior of the produce refrigerator. The log indicated that the temperature was not recorded on the night of September 22, 2025. Inspection of the two-sided kitchen refrigerator with one side designated for dairy and the other for produce revealed the following:
Shredded cabbage dated September 3, 2025, found to be spoiled
Two cases of zucchini dated September 3, 2025, were found to be visibly with green/black color around it.
Case labeled August 20, 2025, containing celery and cabbage: the celery was visibly spoiled.
Cantaloupe dated September 3, 2025, found to be soft to the touch and deemed spoiled
An interview with the Dietary Director Employee E3, confirmed that the produce in question was dated approximately three weeks prior and was found to be spoiled. He was unable to explain why the spoiled produce remained in the refrigerator for such an extended period.
An interview with the Regional Director revealed that additional produce had been received since September 3, 2025 and stored in the walk-in refrigerator. He stated that the spoiled produce had not been used in any meal preparation and could not determine why it was still stored in the refrigerator.
28 Pa Code 20114(a) Responsibility of licensee
| | Plan of Correction - To be completed: 11/18/2025
Immediate corrective action taken:
1) On 9.23.25 during the production of lunch service, during inspection of the walk-in refrigerator, produce items (squash, melon, cabbage, and shredded cabbage) were perceived to be degraded. On 9.23 the temp log for refrigeration containing produce was not filled out properly from PM closing shift on 9.22.
2) Acknowledging the potential impact on all residents due to this deficiency.
3) Immediately and ongoing until October 30, 2024 all dietary staff must participate in and complete the following educations prior to returning to work: Cleaning and Sanitizing In-service; Cleaning Procedures In-services; Cold food storage Policy; Environment Policy and Procedure; Receiving and Storage of Food In-service. Audit: 1) FSD (or designee) will complete F 812 Audit monitoring log 2x daily, 5 days a week, for 60 days. 2) After 60 days, FSD will continue to monitor compliance with F812 via daily management rounds checklist 3) District manager will conduct weekly audit of the kitchen utilizing the district manager unit inspection 1 x weekly for 12 weeks, followed by a monthly assessment of kitchen via District Manager unit inspection, ongoing
Monitor and QAPI:
1. FSD will send completed F-812 monitoring audit to DM and NHA for review weekly.
2. Audits and tracking tool will be sent to NHA on the Friday prior to monthly QAPI meeting.
3. DM will continue to monitor monthly, ongoing, and communicate results to the NHA via Monthly Unit Inspection report.
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