Story Point of Troy

Based on record review, observation, staff interview, and review of facility policies, the facility failed to ensure food was stored and prepared in a manner to protect it from contamination and spoilage. The facility failed to maintain a sanitary environment in the main kitchen, memory care kitchen north and memory care kitchen south, and failed to ensure staff had hair contained in a hair net in food preparation areas. This had the potential to affect all residents residing in the facility who receive their meals from the facility kitchens. The facility census was 65.

Findings Include:

Review of the report titled, Food Inspection Report, dated 10/03/25, revealed the facility was cited for having employee drinks throughout the kitchen preparation area.

Tour of the main kitchen at the facility on 03/04/26 at 8:50 A.M. through 8:55 A.M. with the Dietary Manager (DM) #100 revealed the following findings:

A large bag of trash sitting on the facility kitchen floor next to the food preparation area. The kitchen floor was heavily soiled with dirt, debris, food crumbs, and black substance under the appliance and along the walls. There was a cart next to the food preparation area that was observed with three bottles of water that had been opened and five various thermos cups. The appliances throughout the kitchen were heavily soiled with dried debris and splatter on the sides of the appliances throughout the kitchen. The air handling vents throughout the kitchen and over the food preparation areas were observed to be heavily soiled with dirt and fuzz hanging off them. The trash cans in the kitchen were observed heavily soiled with dried food splatter on the outside of the trash cans.

The reach-in refrigerator was observed with dried/caked white food splatter on the handles, and on the outside front and sides of the reach-in refrigerator. The inside of the reach-in refrigerator was heavily soiled with food crumbs and had the remnants of a cardboard box stuck to the bottom tray along with a pile of crumbs and debris.

The ice-cream freezer was observed to have a heavily soiled top, with crumbs in the cracks of the top sliding door of the freezer. Observation of the inside of the ice-cream freezer revealed ice buildup on the inside of the freezer. There was also observed a brown dried substance on the racks of the freezer. There was an ice-cream lid turned up exposing ice-cream on the lid.

The walk-in refrigerator was observed to contain a large cart with various metal cooking trays which was observed to have the following items: A metal tray contained nine plates with tuna fish salad dated 02/29/26. A metal tray containing 30 rolls which were uncovered, unlabeled and undated. A metal pan of cooked broccoli was dated 02/25/26. A metal pan of cooked squash dated 02/27/26 through 03/03/26. A metal tray contained approximately 20 turkey sandwiches uncovered, unlabeled and undated. A metal tray with approximately 20 unidentified meat sandwiches uncovered, unlabeled and undated. A metal tray with eight individual size pizzas uncovered, unlabeled and undated. A metal tray with eight tossed salads with toppings in a bowl uncovered. The two fans in the walk-in refrigerator were observed to be heavily soiled with dust, dirt, and fuzzy debris hanging from them.

The dish washing area was observed and revealed the wall was heavily soiled with dirt, dried food splatter, and debris. The wall over the sink near the dishwasher was heavily soiled and black spotted substance was observed all around the sink area.

The dry food storage room was observed with multiple boxes stacked directly on the floor. The floor was heavily soiled under the racks of food with dirt, debris, and an unidentified dried liquid.

Interview on 03/04/26 at 8:55 A.M. with DM#100 confirmed the above listed condition of the kitchen regarding the appliances, reach-in refrigerator, ice-cream freezer, walk in refrigerator, dishwashing area, and food storage area. The DM #100 also stated the drinks on the cart near the food preparation table were staff drinks. DM #100 confirmed food stored in the refrigerator should be covered, labeled and dated.

Observation on 03/04/26 at 11:17 A.M. of the memory care south kitchenette revealed Care Associate (CA) #189 prepared the meal with a hair net on the top of his head and his long hair was hanging outside of the hair net. The wall over the counter and sink was observed with brown dried food splatter on the wall and over the sink. The ice machine, dishwasher, and refrigerator were observed with a dried, splattered substances on them. The floor was heavily soiled with dirt, debris, and splatter. The trash can had a dried substance on the outside of the front and sides of the trash can. The memory care kitchenette did not have a food temperature log or a dishwasher temperature log.

Interview with CA #189 on 03/04/26 at 11:17 A.M. confirmed he received the meals from the main kitchen for the memory care south kitchenette. CA #189 stated he did not obtain a temperature of the food when it arrived because the main kitchen staff gathered the temperature of the food prior to it leaving the kitchen. CA #189 confirmed the dried food splatter along the walls over the counter and sink. He confirmed the floors were heavily soiled, the splatter along the fronts of the appliances, and the dried splatter on the outside of the trash can. CA #189 confirmed the memory care kitchenette did not have a temperature log for the dishwasher and did not have a temperature log for the food served from the kitchenette.

Observation on 03/04/26 at 11:23 P.M. of the memory care north kitchenette revealed CA#225 was observed in the memory care north kitchen with her long hair hanging down from a hair net that was placed on the top of her head. There was also observed a large metal bowl of uncovered mandarin oranges in the refrigerator that were unlabeled and undated. Food splatter was observed on the front of the dishwasher, the front of the ice machine, and on the refrigerator. The kitchenette did not contain a food temperature log or a dishwasher temperature log. CA #225 was not observed to obtain food temperatures on the food she was observed to serve to the residents. Concurrent interview with CA #225 confirmed her hair was not contained in the hairnet, the mandarin oranges were uncovered, unlabeled and undated, and the kitchen was not maintained in a sanitary manner. Additionally CA #225 confirmed she did not obtain food temperatures on the food served to the residents, and that there was no food temperature or dishwasher log maintained for this kitchen.

Observation on 03/04/26 at 11:57 A.M. revealed dining server (DS) #124 was standing next the tray line in front of the food preparation area while food was in the process of being prepared with no hair net on. Concurrent interview with DS #124 confirmed they did not have a hair net on and were next to the food preparation area.

Interview on 03/04/26 at 1:36 P.M. with Executive Chef (EC) #119 confirmed the memory care kitchenettes both north and south do not log the dishwasher temperatures. EC #119 confirmed the kitchen staff should be obtaining food temperatures once the meal is delivered to the north and south memory care kitchenette.

Observation on 03/04/26 at 2:04 P.M. revealed two unidentified staff members were standing in the kitchen in front of the food preparation area with no hair net on. Food for the next meal was being prepared. Concurrent interview with DM #100 confirmed two unidentified staff members were standing in the kitchen in the front of the food preparation area with no hair net on and they should have been wearing hair nets. .

Review of the facility policy titled, Standard Operating Procedure, dated 06/06/22 confirmed the purpose of proper food storage is to prevent possible cross contamination and keep food fresh longer. Food must be stored on shelves a minimum of six inches from the ground. The policy stated the facility should maintain proper cleaning and sanitization in the dry food storage area. The cold storage of foods should be properly wrapped and covered and dated with the date opened and the date expired. All cooked or prepped foods need to be in containers that are covered, labeled, and dated with date made and date expires. The facility should maintain proper cleaning and sanitization of all refrigerators and freezers.

Review of the policy titled, Employee Health and Hygiene, dated 06/2017 confirmed cups must be labeled with employee's name and stored away from preparation and serving areas.

Review of the policy titled, Routine Cleaning of Equipment, dated 06/2017 confirmed the facility will have routine cleaning of non-food contact surfaces. The policy stated shelves and carts will be washed with clean cloth. Floor will be swept and cleaned of debris and then mopped and left to dry. Hoods will be cleaned monthly. Walls will be wiped down daily as needed. Air vents in the ceiling will be cleaned quarterly. They will be washed with quat cleaner and then wiped down with a clean towel. Routine cleaning and sanitizing in the equipment and food contact surfaces. All counters will be washed. The outside of appliances will be washed with quat cleaner. All reach in refrigerators will be wiped out daily with a clean cloth soaked in bleach water from sanitizing bucket.

This violation represents non-compliance investigated under Complaint Number OH00169287.

This violation is a recite to Annual Survey completed 11/10/21.

Based on observation, staff interview, and review of facility policies, the facility failed to properly store food and failed to ensure staff had hair contained in food preparation areas. This had the potential to affect all 66 residents residing in the facility who receive their meals from the kitchen. The facility census was 66.

Findings include:

A tour of the facility's kitchen on 11/05/25 beginning at 8:20 A.M. and ending at 8:32 A.M. revealed the following concerns:

In the walk-in refrigerator, there was a pan of asparagus that was on the top of a roll cart rack that was uncovered, undated, and unlabeled. A box of pasta shells was opened and undated. A pan containing six croissant sandwiches was uncovered, undated, and unlabeled. A pan containing what appeared to be a pureed meat was uncovered, unlabeled, and undated. A pan of square waffles was uncovered, undated, and unlabeled. Several other various food items were uncovered, unlabeled, and undated.

Sugar and flour bins had scoops laying directly in the sugar and flour.

In the walk-in freezer ice was forming on the cooling unit and had dripped on top of boxes of french fries that were below it. The boxes of french fries were covered in ice. A pan of scoop round balls that appeared to be meat of some kind were uncovered, undated, and unlabeled.

Cook #20 was in the food preparation area standing between the stove and steamtable. Cook #20 had long black hair with a ponytail that was not contained.

Interview with Sous Chef #10 on 11/05/25 during the kitchen observations confirmed the above findings.

Interview with Cook #20 on 11/05/25 at 8:30 A.M. confirmed she was not wearing a hairnet and did not have her hair contained while in the food preparation area.

Interview and observation with the Administrator on 11/05/25 at 8:45 A.M. confirmed the identified concerns in the walk-in refrigerator and freezer.

Review of the facility's policy titled, Proper Food Storage

Based on observation, staff interview and review of facility policy, the facility failed to ensure food was stored and prepared in a manner to protect it from contamination and spoilage. This had the potential to affect all 70 residents of the facility. The facility census was 70.

Findings include:

Observation on 04/23/25 at 8:04 A.M. of the kitchen walk-in refrigerator revealed a half-covered, undated, and unlabeled pan containing a thick, brown liquid; an opened, undated bag of parsley; an opened, undated package of sundried tomatoes; and an opened, undated bottle of Dijon mustard with an imprinted expiration date of 04/08/25. Continued observation of the walk-in freezer revealed an uncovered, undated, and unlabeled pan of what appeared to be ravioli; an uncovered, unlabeled, and undated sheet pan of what appeared to be cookie dough; and an undated and unlabeled plastic bag of what appeared to be ravioli, with a tear on the bottom corner exposing the food to the air. Observation of the preparation (prep) area revealed an uncovered trash container sitting next to the main cook line and a second uncovered trash container in front of the prep line. Further observation of the dry food storage area revealed an opened, unsealed, and undated bag of rice; an opened, unsealed, and undated bag of cake flour; an opened, unsealed, and undated bag of hard corn tortilla shells, which had a second bag of corn tortilla shells sitting directly on the exposed corn tortillas below it; and four opened and undated beverage syrups. Further observation of the beverage syrup bottles revealed the pumpkin flavored syrup had approximately 10 dead ants floating in the liquid inside the bottle.

Interview on 04/23/25 at 8:30 A.M. with Dietary Manager (DM) #51 verified the above findings. During the interview with DM #51, Dining Assistant (DA) #52 was observed preparing the salad line. DA #52 was not wearing a hairnet or other hair restraint. Further interview with DM #51 revealed all staff entering the kitchen area were required to wear a hairnet and verified DA #52 was not wearing a hairnet and should have had one on.

Review of the facility policy titled, Proper Food Storage, updated 06/06/22, revealed employees were required to store food in airtight containers to keep moisture out and label all open containers with the open date and expiration date in dry stock. Additionally, in cold storage, employees must keep foods properly wrapped or covered and dated with the date opened and date expired and all cooked or prepped foods needed to be in containers that were covered, labeled, and dated with date made and date expired. Lastly, the policy stated food was to be marked anytime the original packaging was opened and anytime ingredients were combined to make something new.

Review of the facility policy titled, Culinary Uniform Standards, reviewed 04/08/25, revealed all chefs/cooks/dietary aids were required, as part of their uniform, to wear a pillbox hat and/or hairnet and they must wear hairnets in the kitchen and dining areas.

This violation is an example of continued noncompliance from the annual survey completed on 11/10/2021.

Based on medical record review, review of the facility incident log, staff interview and policy review, the facility failed to investigate incidents involving residents. This affected one (#14) out of three residents reviewed for incidents. Facility census was 65.

Findings include:

Review of the medical record for Resident #14 revealed an admission date of 08/09/22. Diagnoses included dementia with behavioral disturbances, abnormalities of gait and mobility.

Review of the Brief Cognitive Rating Scale dated 08/29/23 revealed Resident #14 had severe cognitive decline. Review of service plan with a revision date of 12/30/23 revealed she requires assistance with transfers and mobility and frequent checks for safety.

Review of Resident #14's nursing notes revealed on 11/16/2023 at 6:42 A.M. the resident was noted with a one-inch skin tear to the left forearm from unknown origin. Cleansed and steri-strips applied. Physician notified. There was no other documentation regarding the skin tear.

Review of Resident #14's nursing notes revealed 12/22/23 at 6:31 A.M. the resident had bruising to bilateral lower arms documented as unknown origin. On 12/22/23 at 6:38 A.M. nurses notes documented the resident has bruising to bilateral lower arms. Bruise appears purple sand circular. Unknown cause. Resident #14 denies pain. Physician, power of attorney (POA) and Wellness Director notified. On 12/22/23 at 2:16 P.M. nurses notes documented Resident #14's bruising continues, three fingerlike shaped purple bruise to left forearm. Has silver dollar sized purple bruise on right arm. Resident #14 denies pain or tenderness, reported she had disagreement with spouse. Wellness notified and POA notified.

Review of incidents log revealed there was not an incident logged for Resident #14 for a skin tear to left forearm that was documented in the nurses notes on 11/16/23 at 6:42 A.M. Further review of the incident log revealed an incident logged for Resident #14 for bruise of unknown origin was logged on 12/22/23 6:32 A.M. Further review of the facility documentation revealed there was no evidence of investigations for the incidents logged for Resident #14.

Interview on 12/30/23 at 2:07 P.M. with Wellness Director #09 revealed incidents are reported to the Wellness Director via walkie talkie, if in building, or a phone call by the nurses on the floor. Nurses complete the incident report, and the Wellness Director reviews to ensure all charting is completed and interventions are in place. All incidents are reviewed in the morning meeting and all incidents are reviewed in the Wellness Wednesday meeting that covers at risk residents.

Interview on 12/30/23 at 2:28 P.M. with the Executive Director (ED) revealed incidents are not brought to her attention on a day to day, but if there is a concern, they are brought to her. The ED reviews all falls on a daily basis, as well as on Wellness Wednesdays all incidents are reviewed. Will review with family if they would like extra things looked in to.

Interview on 12/30/23 at 2:54 P.M. with the Wellness Director #09 revealed an incident report for Resident #14 was not done on a skin tear to left forearm that was documented in the nurses notes on 11/16/23 at 6:42 A.M. with an unknown origin and that the incident was not logged on the incident log.

Interview on 12/30/23 at 3:25 P.M. with the ED confirmed an incident occurred for Resident #14 on 11/16/23 at 6:42 A.M. was documented as occurring in the resident's nurses notes but was not logged in the incident log and was not investigated. Interview with the ED also confirmed the incident for Resident #14 on 12/22/23 at 2:16 P.M. was documented as resident having fingerlike bruising to bilateral lower arms and that resident stated she had disagreement with spouse