Health inspection·September 17, 2025

§ 483.60 Food and nutrition services. (a) Staffing. The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at § 483.71. This includes: (1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who- (2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services. (c) Menus and nutritional adequacy. Menus must- (3) Be followed. (i) Food safety requirements. The facility must- (2) Store, prepare, distribute, and serve food in accordance with professional standards for food service safety. § 72333 - Dietetic Service-General "Dietetic service" means a service organized, staffed and equipped to assure that food service to patients is safe, and provides for their nutritional needs. § 72341 - Dietetic Service-Menus (c) If any meal served varies from the planned menu, the change and the reason for the change shall be noted in writing on the posted menu in the kitchen. § 72345 - Dietetic-Sanitation (b) All utensils shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seams, cracks and chipped areas. § 72335 - Dietetic Service-Food Service (a) The dietetic service shall provide food of the quality and quantity to meet each patient's needs in accordance with the physicians' orders and to meet the "Dietary Reference Intakes: The Essential Guide to Nutrient Requirements" (2006) by the National Research Council of the National Academy of Sciences, Institute of Medicine, hereby incorporated by reference, and the following: (7) Recipes for all items that are prepared for regular and therapeutic diets shall be available and used to prepare, in which nutritive values, flavor and appearance are conserved. Food should be served at appropriate temperatures. On 8/11/1015, the California Department of Public Health (CDPH) received a complaint regarding dietary services not following the prescribed menu and poor food supply management. On 8/12/2025, an unannounced visit was conducted at the facility to investigate the allegations. The facility failed to ensure safe dietary services were provided to 88 residents who were served food from the kitchen, when: 1. On 8/13/2025, from 5:30 am to 2:25 pm, liquid eggs (processed form of whole eggs, also known as cartoned eggs) were thawed (defrost) at room temperature (ambient temperature [actual temperature] measured by a thermometer around 73 degrees Fahrenheit ([° F]- a unit of temperature) without monitoring the time and temperatures. Liquid eggs were at 55°F which was within the danger zone ([41-135 °F] temperature range where bacteria grow quickly). 2. On 8/13/2025 from 12:10 p.m. to 1:30 p.m., ground beef was thawed at room temperature without time and temperature monitoring. At 12:10 p.m., the ground beef was at 64 °F. At 1:30 p.m., Cook 3 placed the ground beef back into the refrigerator (fridge). 3. Cook 1 failed to check food temperatures (refers to the safe internal cooking temperatures for various types of food to prevent foodborne illnesses) of the regular, mechanical soft and pureed food preparations of beef steaks, mashed potatoes, and a carrot and green bean mix while cooking lunch on 8/12/2025 and the regular, mechanical soft, and pureed food preparations of grits, scrambled eggs, ground turkey, and turkey sausage while cooking breakfast on 8/13/2025. 4. Cook 1 failed to check trayline (an assembly line to plate food for meals) food temperatures for lunch on 8/12/2025 and breakfast on 8/13/2025. 5. On 8/12/2025, Cook 2 failed to check food cooking temperatures for lunch items. 6. Dietary staff substituted green beans for carrots without the Registered Dietitian's ([RD] licensed healthcare professional who specializes in nutrition and dietetics) approval. 7. Cook 1 did not follow the recipe to thicken pureed food (a texture-modified food for residents who can't handle solid food due to things like chewing or swallowing difficulties, or gut issues) when preparing pureed food for lunch on 8/12/2025 and breakfast on 8/13/2025. 8. Cook 1 did not follow a recipe to make the gravy (sauce) on 8/12/2025 for lunch. 9. On 8/13/2025, Cook 1 used a broken metal whisk (a cooking utensil) to prepare breakfast items. 10. The kitchen did not have any supervision from qualified personnel like a Dietary Supervisor, Dietary Services Manager (DSM), Certified Dietary Manager, or RD for food safety preparation. As a result, there was a potential to cause foodborne illness (any illnesses caused by consuming foods or beverages contaminated with harmful bacteria, viruses and parasites or their toxins), food allergies, medical complications such as malnourishment (excesses or imbalances in a resident's intake of nutrients and or energy), choking (blockage of the upper airway by food or other objects that prevents breathing), aspiration pneumonia (a lung infection caused by inhaling oral contents into the lungs) to the 88 residents who received food from the kitchen, hospitalizations and deaths. 1). During an observation on 8/13/2025 at 6:15 a.m. in the kitchen, a (cardboard [heavyweight paper-based]) box (container used for packaging) labelled "Liquid Egg Product" and "Keep Refrigerated 33° F - 40° F" was on the countertop next to the stove. The cardboard box contained a bag filled with yellow liquid eggs that was cold and hard to touch. During a concurrent interview and record review on 8/13/2025 at 9:53 a.m., with Registered Nurse (RN 1), the facility's policy and procedure (P&P) titled, "Food Preparation," dated 2023, was reviewed. RN 1 stated the P&P indicated food preparation should be supervised by the Director of Food and Nutrition Services and reviewed by the Registered Dietitian, employees should prepare food in a safe manner to protect residents from foodborne illnesses and the facility should use proper defrosting methods in defrosting frozen food. RN 1 stated the P&P indicated, prepared food should be stored at proper temperature until serving time and the temperature forms should be utilized. RN 1 stated the P&P also indicated, cold foods must be kept at or under 41° F, and hot foods at or more than 140° F. RN 1 stated food (unspecified) must be kept in safe temperature zones. RN 1 stated there were 88 of 93 residents in the facility who ate food served from the kitchen. RN 1 stated these residents had the potential to develop foodborne illness, dehydration (a state where the body loses more water than it takes in, resulting in a lack of fluid), and hospitalization, if cold food was kept over 41 degrees. During a concurrent observation and interview on 8/13/2025 at 12:10 p.m., with Cook 1 in the kitchen, the box labelled "Liquid Egg Product" and "Keep Refrigerated 33 ° F - 40 ° F" was in the same area on the countertop next to the stove, as previously observed on 8/13/2025 at 6:15 a.m. The box and bag (containing the liquid egg) were wet and felt soft and cold when touched. The temperature of the liquid egg was 55 °F. Cook 1 stated he removed the box of liquid eggs from the freezer on 8/13/2025 at 5:30 a.m. Cook 1 stated the eggs were being thawed until completely defrosted (liquid in consistency). Cook 1 stated Cook 3 would place the box of liquid eggs in the refrigerator that evening to be cooked tomorrow morning. Cook 1 stated he was not trained in how to thaw frozen food. Cook 1 stated countertop thawing at room temperature was standard practice in the facility's kitchen. Cook 1 stated the facility did not have a temperature monitoring log when thawing food and there was no "Pull Schedule" (schedule of when to pull food from the freezer) to thaw. During an interview with RD 1 on 8/13/2025 at 1:00 p.m., RD 1 stated food should never be thawed at room temperature. RD 1 stated thawing food at room temperature was not safe and placed residents at risk of foodborne illness. RD 1 stated the cooks should have thawed the frozen eggs in the refrigerator, or through one of three safe methods to prevent bacterial growth and potential illness in residents. RD 1 stated the cooks should have used one of the following safe thawing options: labelling and placing the liquid eggs in the fridge, fully submerging the bag of liquid eggs under running water or microwaving the bag of eggs. RD 1 stated temperatures of thawing food had to be monitored and recorded throughout the thawing process to limit the amount of time that the food temperature was held in the danger zone. During a concurrent observation and interview on 8/13/2025 at 2:25 p.m. with Cook 3 in the kitchen, the box labelled "Liquid Egg Product" and "Keep Refrigerated 33 ° F - 40 ° F" were observed on the countertop. Cook 3 stated the liquid eggs on the countertop were left to thaw at room temperature. Cook 3 stated she did not measure or record the temperatures and planned to put the liquid eggs in the fridge when fully defrosted to cook on 8/14/2025 for breakfast. Cook 3 stated eggs could be thawed at room temperature because eggs were not meat. Cook 3 stated thawing liquid eggs at room temperature was standard practice in the facility kitchen. During a concurrent interview and record review on 8/13/2025 at 2:35 p.m. with Cook 3, the facility's breakfast, lunch, and dinner menus and recipes dated 8/13/2025 through 8/16/2025 were reviewed. The menus and recipes indicated eggs on the menu for breakfast on 8/14/2025. Cook 3 stated eggs were on the menu on 8/14/2025 for breakfast. Cook 3 stated the liquid eggs in the box on the countertop had been thawing at room temperature for nine hours and were to be prepared for residents' breakfast on 8/14/2025. 2). During a concurrent observation and interview on 8/13/2025 at 12:10 p.m. with Cook 1 in the kitchen, a large tube of red, pink, and white substance was on the countertop. The outside of the plastic tube felt wet, soft and cold. Cook 1 stated the red, pink, and white substance in the cylinder-shape ([cylinder], tumbler shape) was ground beef. Cook 1 stated the temperature of the ground beef was 64 °F. Cook 1 stated the large cylinder of raw, ground beef was removed from the freezer on 8/13/2025 around 9:45 a.m. Cook 1 stated he thawed the raw ground beef at room temperature to cook and serve as a meat option in case he ran out of the planned meat for dinner that evening of 8/13/2025. Cook 1 stated countertop thawing at room temperature was standard practice in the facility's kitchen. During an interview with Cook 3 on 8/13/2025 at 2:25 p.m. in the kitchen. Cook 3 stated the ground beef was placed in the fridge on 8/13/2025 around 1:30 p.m. (3.75 hours) after it was held at room temperature. Cook 3 stated the temperature of the beef was checked and was 39 °F. Cook 3 stated the beef was safe in the fridge and could be cooked for the residents' future meals. During a concurrent interview and record review on 8/13/2025 at 2:35 p.m. with Cook 3, the facility's menu and recipes for 8/13/2025 through 8/18/2025 were reviewed. Cook 3 stated, there was no ground beef on the menu for any meals from 8/13/2025 through 8/16/2025. Cook 3 stated the thawed ground beef could safely be returned in the fridge and stored, cooked, and served to residents within the next week. 3). During an observation on 8/12/2025 from 11:35 a.m. to 12:45 p.m., in the kitchen, Cook 1 did not measure or record food temperatures of the regular, mechanical soft, and pureed food preparations of the beef steaks, mashed potatoes, and the carrot and green bean mix while cooking lunch. During an interview with Cook 1 on 8/12/2025 at 12:00 p.m., Cook 1 stated, he did not have time to monitor or record any food temperatures during cooking. During an observation on 8/13/2025 from 6:15 a.m. to 8:05 a.m. in the kitchen, Cook 1 did not measure or record food temperature when preparing the regular, mechanical soft, and pureed food preparations of grits (corn dish), scrambled eggs, ground turkey, and turkey sausage for breakfast. During an interview with Cook 1 on 8/13/2025 at 8:05 a.m., Cook 1 stated breakfast was served one hour late and he had no time to monitor or record any food temperatures during cooking. During an interview with RN 1 on 8/13/2025 at 9:53 a.m., RN 1 stated food temperatures must be monitored while cooking and serving meals to decrease the risk of foodborne illness and to improve residents' satisfaction. RN 1 stated foodborne illness had the potential to cause residents to be dehydrated and hospitalized. During an interview with RD 1 on 8/13/2025 at 1:00 p.m., RD 1 stated, cooks should follow the facility's P&P when cooking protein items such as beef and chicken. RD 1 stated the P&P indicated Cooks must monitor and record the food cooking temperature in the temperature log. RD 1 stated not monitoring food temperatures may cause undercooked food, food temperatures in the danger zone, bacterial growth and place residents at risk of foodborne illnesses. 4). During an observation on 8/12/2025 at 12:10 p.m., of the lunch trayline, in the kitchen, Cook 1 did not measure or record food temperatures of the regular, mechanical soft, and pureed food preparations of the beef steaks, mashed potatoes, and the carrot and green bean mix for lunch service prior to starting the tray line and serving lunch. During an observation on 8/13/2025 from 6:20 a.m. to 8:05 a.m., of the breakfast trayline in the kitchen, Cook 1 did not measure or record food temperatures prior to starting trayline and serving the regular, mechanical soft, and pureed food preparations of grits, scrambled eggs, ground turkey, and turkey sausage for breakfast. During an interview with Cook 1 on 8/13/2025 at 8:05 a.m., Cook 1 stated he did not have time to measure trayline temperatures prior to serving the regular, mechanical soft, and pureed food preparations of grits, scrambled eggs, ground turkey, and turkey sausage for breakfast on 8/12/2025 and lunch on 8/13/2025. Cook 1 stated he did not know where the Food Temperature Log was and placed. During a concurrent interview and record review on 8/14/2025 at 12:33 p.m. with Cook 2, the facility's Food Temperature Log for 8/2025 was reviewed. Cook 2 stated the Food Temperature Log indicated food temperatures were not measured or recorded for meal items on the following dates and were blank: 1. 8/6/2025, 8/7/2025, 8/8/2025, 8/10/2025, 8/11/2025, 8/12/2025, and 8/13/2025 for hot food served for breakfast. 2. 8/6/2025, 8/7/2025, 8/8/2025, 8/10/2025, 8/11/2025, and 8/12/2025 for hot food served for lunch. 3. 8/6/2025, 8/9/2025, 8/11/2025, and 8/12/2025 for all food served for dinner. Cook 2 stated the Food Temperature Log was only used to record trayline temperatures prior to starting trayline. Cook 2 stated food temperatures were supposed to be measured and recorded prior to starting trayline for every meal. 5). During a concurrent interview and observation on 8/12/2025 at 12:15 p.m., with Cook 2 in the kitchen, Cook 2 did not measure the temperature of ground turkey while cooking. Cook 2 plated (placed on a plate) and served the ground turkey to 16 residents without measuring or recording the temperature. Cook 2 stated he did not check the temperature of the ground turkey. Cook 2 stated the ground turkey was safe for residents' consumption based on the meat's color. Cook 2 stated he had decades of cooking experience and did not need a thermometer (equipment to measure temperature) to check food temperatures. During an observation on 8/12/2025 at 12:45 p.m., CNA 4 served the ground turkey to three residents that was prepared by Cook 2 on 8/12/2025 at 12:15 p.m. with the temperature not measured or recorded. During an interview with RD 1 on 8/13/2025 at 1:00 p.m., RD 1 stated cooked food must reach certain temperatures w