Vancrest Assisted Living of Holgate

Based on observations, staff interviews and review of facility policy, the facility failed to ensure staff served food in a clean and sanitary manner. This had the potential to affect all 35 residents residing at the facility. The facility census was 35.

Findings include:

Observation on 10/15/25 at 12:10 P.M. of the kitchenette tray line revealed Dietary Aid (DA) #101 was observed in the serving area without a hairnet. DA #101 was then observed placing the serving tongs onto paper meal tickets, which were laid out on the steam table prep area. DA #101 then placed the tongs back into the main entree and used them to remove a piece of ham and plate it for serving. Continued observations revealed DA #101 left the tray line on multiple occasions to heat food in the microwave, grab plastic bags containing lettuce, tomatoes and bread. The observations revealed at no time was DA #101 observed to remove her gloves after touching these items. DA #101 was observed to reach into the plastic bag containing lettuce, bread and tomatoes wearing the same set of gloves and proceeded to make sandwiches. There was a hot pad covering the handle of the main entree on the steam table. DA #101 was observed using her right gloved hand to remove the lid with the hot pad, she then turned from the serving area and grabbed a plastic bag containing two pieces of bread. Without removing the gloves, DA #101 reached her right hand into the bag, removed the bread and placed it on the plate.

Interview of the Administrator on 10/15/25 at 12:10 P.M. during the lunch tray line observation revealed DA #101 was required to wear a hair net during the serving of meals and added the dietary aids usually wore hats. The Administrator acknowledged DA #101 had left the tray line on several occasions to retrieve various items and/or to use the microwave and did not remove her gloves prior to returning to the tray line or touching food.

Review of the undated policy titled, Food Preparation and Service

Based observation, staff interview, and review of a facility policy, the facility failed to serve food in a clean and sanitary manner. This had the potential to affect all 27 resident residents residing in the facility. The facility census was 27. Findings Include: Observation of the lunch meal services from the kitchenette on 11/21/24 at 11:53 A.M. revealed Dietary Aide (DA) #201 wore gloves and was using tongs to serve food items from the steam table. There was an oven mitt observed on the handle of the lid covering the main entree on the steam table. Continued observation revealed DA #201 used her gloved hand to touch the oven mitt and handle to remove the lid to serve food, plated food items using the tongs, and then used the tongs to grip the oven mitt and lid handle to place it back over the food. DA #201 then walked the food to residents seated in the dining area. Upon return to the service area, DA #201 again removed the lid from the steam table with her gloved hands, plated food with the tongs, and then used the tongs to grip the oven mitt and lid handle to cover the food. At no time did DA #201 remove her gloves, wash her hands, or sanitize the tongs between using the tongs to grip the oven mitt and lid handle and continuing to use the tongs to serve food. During an interview, at 11/21/24 at 12:07 P.M. with DA #201 confirmed her procedure for plating food and using the tongs to move the steam table lids, indicating that was how she always did it and she was concerned washing her hands too much would make her hands dry. Review of the undated policy titled, Food Preparation and ServiceBased observation, staff interview, and review of a facility policy, the facility failed to serve food in a clean and sanitary manner. This had the potential to affect all 27 resident residents residing in the facility. The facility census was 27.

Findings Include:

Observation of the lunch meal services from the kitchenette on 11/21/24 at 11:53 A.M. revealed Dietary Aide (DA) #201 wore gloves and was using tongs to serve food items from the steam table. There was an oven mitt observed on the handle of the lid covering the main entree on the steam table. Continued observation revealed DA #201 used her gloved hand to touch the oven mitt and handle to remove the lid to serve food, plated food items using the tongs, and then used the tongs to grip the oven mitt and lid handle to place it back over the food. DA #201 then walked the food to residents seated in the dining area. Upon return to the service area, DA #201 again removed the lid from the steam table with her gloved hands, plated food with the tongs, and then used the tongs to grip the oven mitt and lid handle to cover the food. At no time did DA #201 remove her gloves, wash her hands, or sanitize the tongs between using the tongs to grip the oven mitt and lid handle and continuing to use the tongs to serve food.

During an interview, at 11/21/24 at 12:07 P.M. with DA #201 confirmed her procedure for plating food and using the tongs to move the steam table lids, indicating that was how she always did it and she was concerned washing her hands too much would make her hands dry.

Review of the undated policy titled, Food Preparation and Service

Based observation and resident and staff interview, the facility failed to provide hot water in resident bathrooms at acceptable temperatures. This affected two (#19 and #26) of four resident rooms observed. The census was 27.

Findings include:

1. Observation on 11/21/24 at 9:58 A.M. and again at 4:34 P.M. of Resident #19's room revealed the hot water in the bathroom sink was continually monitored for an extended period of time and reached a maximum temperature of 100 degrees Fahrenheit (F).

Interview on 11/21/24 at 4:31 P.M. with Resident #19 stated the hot water in his bathroom sink never got very hot even after it ran for a long time.

2. Observation on 11/21/24 at 10:02 A.M. and again at 4:36 P.M. of Resident #26's room revealed the hot water in the bathroom sink was continually monitored for an extended period of time and reached a maximum water temperature of 100 degrees F.

Interview on 11/21/24 beginning at 4:34 P.M. with Certified Nurse Aide (CNA) #202 verified the hot water temperature in Resident #19's bathroom and Resident #26's bathroom did not exceed 100 degrees F during direct observation.

Based on observation during the kitchen tour and staff interview, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect all 25 residents. The facility census was 25.

Findings:

Observations on 09/27/2022 during the tour in the kitchen at 09:40 A.M. revealed the dishwasher was in use without the use of dish soap. The oven had a build up of heavy black residue and pieces of foil stuck under the rack. There was an unsealed and unlabeled bag of potato wedges and hashbrowns in the freezer.

Interview on 09/27/2022 at 09:45 A.M. with the Director of Dietary verified the dishwasher was out of dish soap. At 09:47 the Director of Dietary verified the unsealed and unlabeled potato wedges and hashbrowns in the freezer. On 09/27/2022 at 09:50 A.M. the Director of Dietary also verified that the oven did have heavy black residue and pieces of foil stuck under the rack. At this same time the Director of Dietary confirmed there was not a routine schedule for cleaning the oven.

Based on review of disaster drills staff interview, the facility failed to conduct disaster drills. This had the potential to affect all 25 residents residing in the facility. The census was 25.

Findings include:

Review of disaster drill reports provided by the facility revealed that no reports were submitted.

Interview on 09/27/22 at 12:43 P.M. with the Administrator verified there was no disaster drill documents for review for 2022.