Willow Brook Christian Home

Based on observation, staff interview, review of facility policy, and review of United States Department of Agriculture (USDA) guidance, the facility failed to ensure safe and sanitary storage of food. This had the potential to affect all 21 residents who received meals at the facility.

Findings Include:

1. Observation on 08/20/25 at 9:26 A.M. in the kitchenette revealed a freezer that contained the following items: a bag of chicken tenders open to air, a bag of French fries open to air, a bag of onion rings open to air, and an unsealed bag of french toast open to air.

Interview on 08/20/25 at 9:26 A.M. with Server #101 verified the items in the freezer were open to air and should be sealed.

2. Observation on 08/20/25 at 9:52 A.M. in the assisted living kitchenette revealed food splatter on three of the oven burners and a tray of cooked bacon was sitting on the counter with plastic wrap partially covering the bacon.

Interview on 08/20/25 at 9:53 A.M. with Server #101 confirmed the food splatter and that bacon was left out on counter after breakfast was served. She said the chef was responsible for that area and she didn't touch it.

Observation on 08/20/25 at 11:16 A.M. in the assisted living kitchenette revealed the tray of cooked bacon was still on counter.

Observation on 08/20/25 at 12:03 P.M. in the assisted living kitchenette revealed the tray of cooked bacon was still on counter.

Interview on 08/20/25 at 12:03 P.M. with Chef #115 verified the bacon on the counter. Chef #115 said it was left out all day and thrown out at the end of the evening. On request Chef #115 checked the temperature of the bacon and reported it to be 68 degrees Fahrenheit (F.). Chef #115 confirmed that he was aware that food above 41 degrees Fahrenheit could develop bacteria.

Review of the facility policy titled, Food Safety dated 08/01/25 revealed food should be stored in a manner that helps prevent deterioration or contamination of the food including from growth of microorganisms.

Review of the United States Department of Agriculture (USDA) publication titled, Bacon and Food Safety updated 05/23/24 revealed cooked bacon should be refrigerated at 40 degrees Fahrenheit.

Based on review of facility fired drills, staff interview, and policy review, the facility failed to ensure residents capable of self-evacuation were actually evacuated to safe areas in at least two fire drills per shift per year. This had the potential to affect all 21 residents residing in the facility. Findings Include: Review of facility fire drill records dated 11/04/24, 12/02/24, 01/07/25, 02/01/25, 03/28/25, 04/27/25, 05/30/25, 06/28/25, 07/25/25 revealed no indication that residents were evacuated to a safe area as part of the fire drill. Interview on 08/20/25 at 1:35 P.M. with Maintenance Supervisor #56 confirmed they had not completed a resident evacuation since January 2025. He said he thought the requirement was twice a year. He confirmed the documentation did not show evidence that a resident evacuation was completed in January 2025. Review of the facility policy titled, Fire Drill PolicyBased on review of facility fired drills, staff interview, and policy review, the facility failed to ensure residents capable of self-evacuation were actually evacuated to safe areas in at least two fire drills per shift per year. This had the potential to affect all 21 residents residing in the facility.

Findings Include:

Review of facility fire drill records dated 11/04/24, 12/02/24, 01/07/25, 02/01/25, 03/28/25, 04/27/25, 05/30/25, 06/28/25, 07/25/25 revealed no indication that residents were evacuated to a safe area as part of the fire drill.

Interview on 08/20/25 at 1:35 P.M. with Maintenance Supervisor #56 confirmed they had not completed a resident evacuation since January 2025. He said he thought the requirement was twice a year. He confirmed the documentation did not show evidence that a resident evacuation was completed in January 2025.

Review of the facility policy titled, Fire Drill Policy