§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 select facility policy, observation, and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness.
Findings include:
Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food).
A review of a facility policy entitled "Food Storage Labeling and Dating Policy" indicated refrigerated food items shall be maintained at a temperature that keeps potentially hazardous/perishable foods at safe temperatures in accordance with applicable food safety requirements. Refrigerator temperatures shall be monitored and documented according to the facility's temperature monitoring procedure. Food leftovers shall be labeled with the name of the food, the date it was prepared or opened, the discard by or use-by-date, and the initials of the employee. The refrigerators and freezers shall have functioning thermometers. Food temperatures and equipment temperatures shall be monitored and recorded.
The facility's policy entitled "Use and Storage of Food Brought in by Family or Visitors" indicated the facility may refrigerate labeled and dated prepared items in the nourishment refrigerator. All food items must be already prepared by the family or visitor, and food must be labeled with content and date. The prepared items brought into the facility must be consumed within three days. If not consumed within three days, food will be thrown away by facility staff.
The initial tour of the dietary department conducted on September 1, 2026, at 11:15 AM, revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness, were identified:
Observations of the counter where the coffee maker was placed revealed 2 large rags placed in a bucket next to the coffee maker. The countertop was observed to bet wet with what appeared to be a mix of brown and clear liquid.
Interview with Employee 1, cook at the time of observation revealed the coffee maker leaks, and they use the rags to capture the water/coffee that leaks from the equipment. Employee 1 stated the rags should have been discarded.
Observations of the condenser fan, inside of the department's produce cooler, was corroded with ice crystals. The dietary manager reported that maintenance department was aware. However, the facility could not provide documented evidence of identifying ice corrosion covering the walk-in cooler prior to the surveyor's inspection.
Observations inside the walk-in refrigerator revealed underneath the food storage shelving and perimeter of the room, observed debris, food particles, butter packets, premade sausage, juice containers, dried droplets of a red substance, and several deceased insects.
Observations of the facility's freezer in the presence of Employee 1 on September 1, 2026, at 08:45AM, revealed food to be stored in the freezer, including hot dogs, burgers, and multiple other closed boxes of frozen food. The freezer was observed to have a temperature reading of 5 degrees Fahrenheit. Employee 1 stated the food stored in the freezer currently was being used for the alternative menu for residents who wanted burgers, or hotdogs.
Observations of the inside of the dietary refrigerator contained the following items that were opened and unlabeled: a 5-pound container of cottage cheese, readily available for use with a manufacturer expiration date of August 23, 2026. A bottle of Thick and easy thickened dairy beverage, a container of premade juice, 3 containers of salad dressing, and a jar of mayonnaise.
Observation outside of the refrigerator on a serving cart revealed a container labeled "Egg Salad" with a prepared date of August 26, 2026, the container was warm to touch, with visual perspiration on the outside of the container. Interview with Employee 1 at the time of observation revealed the container had been left out for about an hour at the time of observation.
Observations of the refrigerator behind the nursing unit upon entry to the facility revealed the following opened and unlabeled items:
A container with what appeared to be Chinese food with a receipt of "Singapore Chow Mei Fun" with a purchase date on the receipt of July 29, 2026, a half-eaten, roast beef store bought sandwich with a sell by date of August 21, 2026, 3 undated mighty shakes, 8 puddings, 1 bag of grapes, 6 peanut butter sandwiches in zip lock baggies, 3 undated, 2 cheese sticks with a date of July 26, 2026, and 3 prune juices dated August 11, 2026.
Interview with the Nursing Home Administrator (NHA) on September 1, 2026, at 2:00 PM, reviewed the findings of the unsanitary conditions in the kitchen and food storage areas in the dietary department and resident nourishment room areas were to be maintained in a sanitary manner to ensure food safety.
28 Pa. Code 201.18 (e) (2.1) Management.
28 Pa. Code 211.6 (f) Dietary Services.
| | Plan of Correction - To be completed: 09/23/2026
Corrective Action
The facility immediately corrected the unsanitary conditions and removed all food items that were not in compliance with facility policy and food safety standards. All affected food storage areas and food preparation surfaces were cleaned and sanitized, refrigeration and freezer units were evaluated to ensure proper operation and temperatures, and any equipment requiring repair was immediately addressed through the facility's maintenance process. Staff received immediate education regarding proper food handling, storage, labeling, dating, sanitation practices, and adherence to facility policies. These actions were implemented immediately to ensure the safety of all residents and to prevent the potential for foodborne illness.
Identification of Concerns
To identify any additional concerns, the dietary manager/designee conducted an audit of all dietary storage areas, food preparation areas, refrigeration and freezer units, and nursing unit nourishment refrigerators. Any items found to be out of compliance with facility policy or food safety standards were immediately corrected or discarded. Any identified concerns were addressed promptly to ensure compliance with applicable food safety regulations and facility policies
Systemic Changes
The administrator/designee re-educated the Dietary Manager on federal and state food sanitation requirements, including F812 requirements. The administrator/designee educated dietary staff, nursing staff, and maintenance staff regarding food safety, proper food storage, labeling and dating, sanitation, temperature monitoring, equipment maintenance, facility policy regarding food brought in by families and visitors, and disposal of non-compliant food items. Monitoring tools and checklists have been implemented to provide consistent oversight of dietary areas, food storage, refrigeration/freezer temperatures, sanitation, and equipment.
Ongoing Monitoring and Quality Assurance
The Dietary Manager/designee will complete weekly food storage audits daily x 2 weeks and weekly 2 weeks, and monthly x2 months. Audits will include food temperatures, labeling/dating, expired food, storage practices, sanitation, equipment condition, food carts, and nourishment refrigerators.
The administrator/designee will complete weekly environmental/maintenance inspections of the kitchen, walk-in refrigerator, and walk-in freezer x 4 weeks and monthly x 2 months. Any identified deficiency will be corrected immediately. Findings will be reviewed during the monthly Quality Assurance Committee meetings x 3 months.
Date of Compliance: September 23, 2026
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