§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, interviews with staff and review of facility policy it was determined that the facility failed to ensure that food items were stored prepared and served according to professional standards.
Findings include:
Review of facility policy on food storage dating and labeling with the most recent review date of April 2026 reveal that under section "POLICY-Sufficient storage facilities are provided to keep foods safe, wholesome and appetizing. Food is stored in an area that is clean, dry and free from contaminants. Food is stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination or cross contamination." Under section "Procedure: #1. Dry storage rooms must be well ventilated. All storage areas should have adequate illumination with temperature and humidity controls to prevent condensation of moisture and growth of molds. # 3. Food items will be stored on shelves, with heavier and bulkier items stored on lower shelves. # 8. All stock must be rotated with each new order received. Rotating stock is essential to ensure the freshness and highest quality of all foods. a. Old stock is always used first (first in first out method). b. Supervise the person designated to put stock away to make sure it is rotated properly. c. Food should be dated as it is placed on the shelves. d. Date marking to indicate the date or day by which a ready-to eat, potentially hazardous food should be consumed, sold or discarded will be visible on all high risk food (see chart on next page). e. Foods will be stored and handled to maintain the integrity of the packaging until ready for use. (Food stored in bins may be removed from its original packaging.) # 12. Perishable food such as meat, poultry, fish, dairy products, fruits, vegetables and frozen products must be frozen or stored in the refrigerator or freezer immediately after receipt to ensure nutritive value and quality. Refrigeration temperatures should be thermostatically controlled to maintain food temperatures at or below 41F and freezer temperatures to keep food frozen solid. # 13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 5 days or discarded. (Also see policy on Use of Leftovers in this section.) # 14. Refrigerated Food Storage: a. All refrigerator units are kept clean and in good working condition at all times. b. PHF/TCS foods must be maintained at or below 41unless otherwise specified by law. Periodically take temperatures of refrigerated foods to assure temperatures are maintained at or below 41F. Temperatures for refrigerators should be between 35-39F. Thermometer should be checked at least two times each day. Check for proper functioning of the unit at the same time. c. Every refrigerator must be equipped with an internal thermometer. f. All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable) or discarded. g. All foods should be stored to allow air circulation. h. Refrigerated foods should be stored upon delivery and careful rotation procedures should be followed. 15. Frozen Foods: a. All freezer units are kept clean and in good working condition at all times. b. Frozen foods must be maintained at a temperature to keep the food frozen solid. Temperatures for the freezer should be cold enough to keep food frozen solid and should be checked at least two times each day. Check for proper functioning of the unit at the same time. Periodically, check the firmness of foods in the freezer to assure temperatures are maintained to keep food frozen solid. d. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. All foods should be checked so as to show no negative outcome (e.g., freezer burn, foods dried out, foods with a change in color). e. All foods should be checked for signs of negative outcome. (freezer burn, foods dried out) f. All foods will be stored to allow adequate air circulation. g. All food items should be stored upon delivery and careful rotation procedures should be followed.
Observation of a storage room located in the facility's basement on May 14, 2026, at 11:58AM, in the company of with Business Office Manager, Employee E4 revealed that the room was full of food items such as boxes of chips, candies, packs of water, and soda. Further observation of the storage room also revealed other nonfood items such as unopened Amazon bag. Further, food was stored in random areas of the storage room.
Observation of the storage room located in the facility's basement on May 14, 2026, at 11:58 a.m. in the company of Employee E4 revealed three opened honey mustard sauce on a shelf in the storage room outside of the refrigerator. Two of the honey mustard sauce had a "best by" date of November 22, 2025, and one had a "best by" date of November 9, 2025. Further the container of the honey mustard sauce indicated "Refrigerate after opening".
Observation of the refrigerator in the storage room located next to the conference room revealed that the refrigerator was packed with food items. A box of fresh eggs, an open box containing 16 fresh eggs, open salad dressings Pickles whipped cream open soda bottles open mustard bottles open ketchup bottles, a blue plastic container with blue cover containing a grayish brown unknown material.
Further, observation of the refrigerator revealed two salted butter with a best by date of September 17, 2024. There wasdried up materials on the bottom of the refrigerator and on the shelves.
Observation of the top freezer of the refrigerator revealed that the freezer was packed with frozen food items. Freezer contained 2 containers of ice cream and a box of fruit ice pops behind it further a blue bowl loosely covered with aluminum foil containing dried up brownish material was on top of the ice cream further, the bowl did not have a date on it. Further, loose ice pops with no dates affixed to them were at the bottom of the freezer. Further, two bags of undated frozen brown material in a large zip-lock bags were on top of the loose ice pops. Further, the shelves of the freezer door contained 2 packs of sausages.
Further observation revealed that the bottom of the freezer had a dried-up brownish-reddish substance. There was no thermometer observed in the freezer.
Interview with Business Office Manager, Employee E4 conducted at the time of the observation revealed that Employee E4 conducts a fund raiser on a regular basis involving the sale of sausages, bread, chili cheese and sour kraut. Further, Employee E4 revealed that the kitchen was aware of the sausage sale but was not involved with the process and that Therapeutic Recreation and a few nursing employees help cook and serve during the event.
Further interview with Employee E4 also revealed that she purchases all the food items and she brings them in the morning of the sale. Further Employee E4 revealed that if she buys the food items ahead of time, she brings the food items in and places them in the refrigerator located in the storage area. Further, Employee E4 revealed that on the day of the fundraising sale, a hot dog roller grill (A machine used to cook hot dogs on rotating cylinders) is set up in the dining room and the sausages are then cooked there. Further, Employee E4 revealed Kitchen staff are not involved during the sale event.
Further interview with Employee E4 revealed that food temperatures are not checked at any time during the storage and cooking of the food items. Further, Employee E4 also revealed that the refrigerator temperature was not checked regularly for proper temperature storage of food. Further, Employee E4 revealed that there were no temperature logs, refrigerator check logs and other documented evidence that the temperature of the refrigerator was monitored, food items were regularly monitored.
Interview with Director of Therapeutic Recreation Employee E6 conducted April 14, 2026, at 11:42AM revealed that the Therapeutic Recreation department is not in charge with the fundraising involving the sale of sausages, bread, chili cheese and sauerkraut. Further EmployeeE6 revealed that the role of the Therapeutic Recreation during the event is to help cook and serve the food. Further, Employee E6 revealed that Therapeutic Recreation Department was not involved with the purchase and storage of the food items used during the fundraiser.
Interview with Dietary Director, Employee E5 conducted on April 14, 2026, at 1:30 PM revealed that the kitchen was not involved in the food storage and food preparation process for the fundraising event conducted by Business Office Manager Employee E4. Further, Employee 5 revealed that Employee E4 is responsible for purchasing, storing, preparing, cooking, sale and serving the food to residents and staff.
Further Dietary Director, Employee E5 revealed that moving forward the kitchen will be responsible for purchasing storing the food items used for the fundraising.
Interview with Regional Nurse Employee E3 conducted on April 14, 2026, at 1:53PM during a follow-up observation of the refrigerator and freezer in the storage room confirmed that the refrigerator contained open soda bottles, open mustard bottles open ketchup bottles, a blue plastic container with blue cover containing a grayish brown unknown material, two salted butter with a best by date of September 17, 2024, dried up substance on the bottom of the refrigerator and on the shelves and that the freeze contained an undated blue bowl loosely covered with aluminum foil containing dried up brownish material was on top of two ice cream container, loose ice pops with no dates affixed to them, two bags of undated frozen brown material in a large sized zip-lock bags on top of the loose ice pops, the bottom of the freezer had a dried up brownish/reddish material and that the freezer did not have a thermometer.
28 Pa. Code 201.18(b)(3)(2.10 Management
| | Plan of Correction - To be completed: 05/05/2026
The refrigerator as well as all the foods, beverages, and snacks have been removed from the basement storage area, and the storage area has been thoroughly cleaned.
Full facility audit has been conducted to ensure that all foods, beverages and snacks are properly stored, labeled and dated. All are in the facility kitchen and all are in compliance.
E4 was educated regarding the importance of bringing all fundraiser foods, beverages and snacks to the Dietary Manager for proper storage, procurement and handling and in the facility kitchen.
All foods and beverages and snacks used for fundraisers will be stored, managed, and cooked by the Dietary Manager or designee from the dietary department, according to federal, state and local regulations as well as facility policy.
Fundraiser items will be audited to ensure proper storage and procurement weekly x 4 weeks, then monthly thereafter.
Results will be reported in monthly QAPI
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