SAN DIEGO, CA - Federal health inspectors documented mold growth inside ice-making equipment, black speckled debris embedded in ice cubes, and a pattern of food safety breakdowns at Casa De Las Campanas, a 50-bed nursing home located at 18655 W. Bernardo Drive in San Diego, during a June 2024 inspection.
Mold-Contaminated Ice Machines Producing Tainted Ice
The most alarming finding during the federal survey involved the facility's ice machines, which are used daily to provide ice for resident beverages and other needs. Inspectors touring the main production kitchen on June 4, 2024, observed that when the ice machine bin door was lifted, five ice cubes sitting at the top of the pile contained visible small black speckled debris. When the top cover of the machine was opened, inspectors found black and grayish colored mold-like spots on the top edges of the ice machine curtain — the front panel that serves as insulation for the unit.
The interior walls of the ice machine also displayed yellow-pinkish colored spots on the left and right side corners where they contacted the baffle, the component designed to guide freshly formed ice into the bin. On the exterior, the rubber seals in the upper corners of the ice bin were covered with white calcium-like deposits and were torn and detaching. A broken plastic piece on the outer right corner of the bin door left a large gaping hole.
A review of the facility's ice machine maintenance log revealed that the most recent cleaning had begun on January 16, 2023, with filter changes recorded on irregular dates. The filters connected to the machine had a label indicating an installation date but no replacement date was recorded. According to the facility contractor who demonstrated the cleaning process, his company does not clean the baffle inside the ice bin or change out the water filters — two critical components for maintaining sanitary ice production.
The facility's Dietary Supervisor, Food and Beverage Director, and Executive Chef each acknowledged the contamination when shown the evidence by inspectors, including the discolored debris in the machine and the ice cubes containing black speckles.
Mold growth in ice machines represents a meaningful food safety risk in healthcare settings. Species commonly found in poorly maintained ice machines — including Aspergillus, Penicillium, and various biofilm-forming bacteria — can pose particular dangers to elderly and immunocompromised individuals. Nursing home residents, many of whom have weakened immune systems, are significantly more vulnerable to infections caused by mold and bacterial contamination in food and beverages.
Plumbing Deficiencies Created Backflow Contamination Risk
Inspectors identified a second systemic problem with the facility's ice machines: improper air gap configurations in the plumbing connections. In the health center kitchen, the ice machine's air gap system was piped directly through a food production sink pipe underneath the sink station. In the main production kitchen, a white PVC pipe attached to the ice machine was pushed directly down into a floor sink drain. A similar configuration was found at the nurse's station nourishment room, where a long PVC pipe extended from the back of the ice machine directly into the floor sink drain.
Air gaps are a critical backflow prevention measure required by the FDA Food Code. They create a physical separation between a water supply line and any potential source of contamination, preventing sewage or drain water from being siphoned back into equipment that produces food or ice. The 2022 Federal FDA Food Code requires an air gap of at least twice the diameter of the water supply inlet, and no less than 25 millimeters (1 inch).
The Food and Beverage Director acknowledged that the PVC pipe in the main kitchen "should be raised higher." The Director of Plant Operations agreed that proper air gap spacing was needed between the floor sink drains and the pipes, stating he expected all equipment to be working operationally and on a preventive maintenance cleaning schedule.
Without proper air gaps, contaminated water from floor drains could theoretically flow backward into the ice-making equipment, introducing sewage-related bacteria and pathogens directly into ice consumed by residents.
Refrigerator Contamination and Worn Equipment
The inspection also revealed contamination in the facility's food storage equipment. In both the health center kitchen and the main production kitchen, reach-in refrigerator door gaskets were found coated with brown and black sticky grime, along with grayish spots on interior door panels. Gaskets in the health center kitchen were physically deteriorating, with tears at the top and bottom corners and sections detaching from the sides. A second refrigerator in the main production kitchen had a heavily worn gasket with pieces torn off and detaching from corners.
Refrigerator door gaskets serve a dual purpose: they maintain the cold temperatures necessary for safe food storage, and they create a sealed environment that limits exposure to outside contaminants. When gaskets are torn, grimy, or detaching, they compromise both functions. Damaged seals can allow temperature fluctuations that accelerate bacterial growth in stored food, while accumulated grime on gasket surfaces can harbor harmful microorganisms that may transfer to food items.
The facility's Registered Dietitian stated she was unaware of the kitchen cleaning and sanitation concerns identified in both kitchens. The Dietary Supervisor confirmed that all reach-in refrigerator door gaskets should have been on both kitchens' daily and weekly cleaning schedules. When inspectors requested cleaning schedules and logs for the refrigerators, the facility was unable to provide them.
Uncovered Food and Cross-Contamination Risks
Inspectors observed multiple instances of food being stored or transported without proper covering. In the health center refrigerator, a long metal tray holding 20 individually sliced chocolate mini dessert cakes was found stored uncovered, with additional uncovered slices on an adjacent shelf. The Dietary Supervisor and Food and Beverage Director acknowledged the items needed to be covered to prevent cross-contamination.
On a separate occasion, two dietary aides were observed pushing a food cart through the elevator kitchen with uncovered cookies and desserts on open trays. Both staff members told inspectors they "were in a rush to get the food item from the main production kitchen to the health center kitchen" and declined further interview.
The facility's own policy, titled "Food Storage" and dated 2013, clearly states that "all exposed foods should be tightly covered." Uncovered food in refrigerators and during transport is vulnerable to contamination from airborne particles, dripping liquids from items stored above, and contact with unclean surfaces.
Worn Cutting Boards and Compromised Food Prep Surfaces
At the health center food prep station, inspectors found 12 cutting boards with heavily worn deep knife cuts and grooves, along with large white discoloration across their surfaces. Staff attributed the discoloration to the sanitizer used in the high-temperature dish machine, but the deep grooves represent a more concerning issue.
Cutting boards with deep cuts and grooves cannot be adequately sanitized, as bacteria become trapped in the crevices where cleaning solutions and sanitizers cannot reach. The FDA Food Code requires that equipment and food-contact surfaces be "clean to sight and touch." The Food and Beverage Director and Dietary Supervisor acknowledged the boards needed to be replaced.
Expired Food and Inconsistent Storage Policies
Inspectors also documented failures in the facility's handling of food brought in by residents' family members. In the nourishment room refrigerator at nursing station 2, a 32-ounce bottle of orange juice was found labeled only with a room number and expired past its "best if used by" date. The item lacked proper identification with a resident's name and date as required by facility policy.
Interviews revealed conflicting understanding among staff about the facility's own food storage rules. A Certified Nursing Assistant stated outside food "should not be kept more than a week," while the Director of Nursing and Director of Staff Development both stated the correct timeframe was 72 hours — consistent with the facility's written policy. The Director of Staff Development acknowledged, "I agree that we should have an in-service on our outside food policy — it should be discarded within 72 hours and not one week."
The Director of Nursing stated that outside food should not be stored in the nursing station refrigerator at all, but rather in a separate resident nourishment fridge in the dining room, and that the facility needed to update its policy to reflect correct practice.
Infection Control Lapses
Beyond food safety, inspectors documented an infection control violation when a Medical Records Staff member entered a resident's room to answer a call light without performing hand hygiene. The staff member acknowledged to inspectors that hand washing should have been performed before entering. The facility's Infection Preventionist, Director of Staff Development, and Director of Nursing all confirmed the lapse violated policy and standard infection prevention protocols.
The facility's own Handwashing/Hand Hygiene policy, revised in October 2023, states that "all personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections."
Outdated Policies and Systemic Oversight Gaps
A recurring theme across the inspection findings was the age of the facility's governing policies. Multiple policies cited during the survey — including Food Storage, Outside Food, and Equipment Maintenance — dated to 2013, more than a decade before the inspection. While older policies are not inherently deficient, the gap between written standards and actual practice suggests these documents had not been meaningfully reviewed or reinforced through staff training in recent years.
The combined violations resulted in citations under F-tags F0812 (food safety and sanitation), F0813 (outside food storage policies), F0880 (infection prevention and control), and F0908 (equipment maintenance). All citations were classified at the level of minimal harm or potential for actual harm.
Casa De Las Campanas has 30 days from receiving the inspection report to submit a plan of correction to the Centers for Medicare & Medicaid Services. For the full inspection report and deficiency details, readers can visit the CMS Care Compare website or contact the California Department of Public Health.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Casa De Las Campanas from 2024-06-07 including all violations, facility responses, and corrective action plans.
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