Ashton at Anderson, The

Based on observation, interview, and policy review the facility failed to ensure food was stored and prepared to prevent risk of contamination and food borne illness. This had the potential to affect all residents as the facility identified all residents receive food from the kitchen. The facility census was 91.

Findings include:

Observations of the kitchen on 10/15/25 from 9:07 A.M. to 9:24 A.M. with Dinning Service Chef (DSC) #30, revealed the following:

a) The freezer contained a container of opened and undated sausage links, chicken breast, and chocolate chip cookie dough.

b) There were two boxes of Styrofoam containers and a box of insulated bowls being stored on the floor in the dry storage room and active dry yeast and spaghetti noodles were opened and undated.

c) The walk-in cooler contained blue cheese dressing, French dressing, and three containers of poppy seed dressing open and undated along with a container or thousand island dressing with a discard date of 9/30/25. ) The microwave had a build up of food debris.

e) The freezer near the deep fryer contained three bags of chicken breast, two bags of fries, two bags of hash browns, and two backs of nuggets open and undated.

f) The meat slicer had a build-up on the blade and the ice maker contained a black residue inside the ice machine.

Interview with DSC #30 on 10/15/24 at 9:24 A.M., verified the findings in the kitchen.

Observation of the lunch service on 10/15/25 at 12:19 P.M. with Dining Service Assistant (DSA) #19, revealed the cucumber salad was 62 degrees Fahrenheit and the pudding was 63 degrees Fahrenheit. Interview with DSA #19 at the same time, verified the temperatures of the cucumber salad and the pudding.

Review of the facility policy titled, Food Storage, Handling and Labeling dated 07/01/22, revealed all food in the refrigerator walk-in, freezer and storage areas should be properly labeled and include produced-on and use-by dates.

Review of the facility policy titled, Dinning Services Food Preparation Guideline dated 07/01/22, revealed that cold foods should be stored below 41 degrees Fahrenheit.

This violation is a recite to annual survey completed 12/11/24.

Based on observation, staff interview, record review, and policy review, the facility failed to ensure the dietary staff were educated on following recipes and spreadsheets during meals to ensure residents received adequate nutrition. This affected three (#63, #76, and #91) of the three residents who received a mechanical soft diet. The facility census was 91.

Findings include:

Review of the facility list of resident diets identified three residents, Resident #63, #76, and #91 who required a therapeutic (mechanical soft) diet. All other residents in the facility received regular diets from the kitchen.

Interview on 10/15/25 at 11:46 A.M. with Dinning Service Chef (DSC) #30, verified the facility does not have recipes for preparing therapeutic diets and that they have not received training from the Registered Dietician (RD).

Observation of the lunch service on 10/15/25 at 12:00 P.M., revealed residents with a mechanical soft diet were served soup and a chicken patty with pudding for dessert.

Review of the menu for 10/15/25, revealed lunch included vegetable medley soup, chicken club sandwich, cucumber dill salad, french fries, and banana pudding.

Interview on 10/15/25 at 12:12 P.M. with Nursing Aide #07, verified the residents with mechanical soft diets only received a bowl of soup, a chopped chicken patty, and pudding.

Review of the facility policy titled, Food Therapeutic Diets dated 07/01/22 revealed orders for special diets must be followed carefully, as deviation from the ordered diet may result in serious health consequences.

Based on record review, staff interview and policy review, the facility failed ensure silent alarms were conducted between the hours of 9:00 P.M. and 6:00 A.M. The facility failed to verify fire alarm signals were transmitted and received within the allotted time following the fire drill. This had the potential to affect all residents. The facility census was 91.

Findings include:

Review of the facility fire drills revealed silent drills were conducted for second shift on 01/30/25 at 10:00 P.M., 04/29/25 at 5:30 P.M., and 07/24/25 at 10:30 P.M..

Review of the facility fire drills revealed silent drills were conducted for third shift on 02/27/25 at 11:30 P.M., 05/18/25 at 1:00 A.M. and 08/21/25 at 5:30 A.M..

Further review of the fire drill records revealed there was no record of signal transmission received after the silent drills.

Interview on 10/15/25 at 2:26 P.M. with Maintenance Director #49, verified a silent alarm was conducted on 04/29/24 at 5:30 P.M. Maintenance Director #49 verified the facility did not transmit a signal after each silent fire drill.

Review of the undated facility policy titled, Fire Safety revealed that the fire alarm monitoring company should be contacted prior to starting and after each fire drill. Further review reveal that silent drills can be conducted between the hours of 9:00 P.M. and 6:00 A.M.

Based on record review and staff interview, the facility failed to ensure fire drills contained all the required information. This had the potential to affect all residents residing in the facility. The facility census was 91.

Findings include:

Review of the fire drill documentation from 12/19/24 to 09/19/25, revealed the facility did not include staff members in attendance, number of individuals evacuated, and total time for evacuation. The drills were conducted on 12/19/25, 01/20/25, 02/27/25, 03/24/25, 04/29/25, 05/18/25, 06/29/25, 07/24/25, 08/21/25, and 09/19/25.

Interview on 10/22/25 at 02:26 P.M. with Maintenance Director #49, verified the fire drills did not include members in attendance, number of individuals evacuated, and total time for evacuation.

Based on observation, staff interview, and review of the facility policy, the facility failed to label, date, and store foods in a safe and sanitary manner. This had the potential to affect all of the residents residing in the facility. The facility census was 85 residents.

Findings include:

Observation on 12/11/24 at 9:15 A.M of facility kitchen revealed the following unlabeled and undated items were stored in the refrigerators: two containers of coleslaw, a container of liquid eggs, a bottled of salad dressing, an open carton of milk. The following open, undated, and unlabeled items were in the dry storage area: a bottle of teriyaki sauce, a bottle of soy sauce, a jar of honey.

Interview on 12/11/24 at 9:20 A.M. with the Food Service Director (FSD) confirmed there were unlabeled and undated items in the refrigerators and dry storage area of the kitchen.

Observation on 12/11/24 at 3:50 P.M. revealed there were two pans raw chicken breasts which were uncovered and open to air in the walk-in refrigerator.

Interview on 12/11/24 at 3:51 P.M. with the FSD confirmed the chicken breasts were uncovered and open to air in the refrigerator. The FSD confirmed staff should have covered the chicken breasts and labeled and dated them prior to storing them in the refrigerator.

Review of the facility policy titled Food Storage dated 07/01/22 revealed all refrigerated food must be wrapped or covered and dated. Food items should have a label indicating item name, date produced, a use-by date and the employee's initials.