SANTA ANA, CA - Federal health inspectors documented a pattern of food safety failures at St Edna Subacute and Rehabilitation Center during a June 2024 survey, finding that kitchen staff repeatedly failed to follow basic hygiene protocols while preparing meals for the facility's 122 residents.
Repeated Handwashing Failures During Food Preparation
During observations spanning multiple days in June 2024, surveyors witnessed three of 11 kitchen employees fail to follow proper hand hygiene procedures — a fundamental food safety practice required by the facility's own policies.
On June 18, 2024, one cook was observed touching a trash can to discard used gloves, then putting on new gloves without washing her hands. When interviewed by inspectors, the cook stated "her hands were not dirty, so she did not wash her hands," adding that she had only changed her gloves. The following day, the same cook was observed removing gloves and donning a new pair without handwashing during puree preparation of Vietnamese foods.
A dietary aide was observed on June 19, 2024 donning gloves without washing her hands on two separate occasions during puree food preparation, after touching multiple surfaces with ungloved hands. Later that same day, during the lunch meal tray line, the aide was again observed removing gloves and putting on a new pair without performing hand hygiene while cooking ham.
A third kitchen employee, a dietary aide hired in January 2024, was observed on June 18, 2024 loading soiled dishes into the dish machine with gloved hands, removing the gloves, placing his bare hands into a sanitizing solution in a bucket, then handling clean dishes — all without washing his hands at any point in the process.
The facility's own policy, titled "Hand washing techniques" and effective since February 2009, explicitly requires handwashing after removal of gloves and after handling soiled dishes. The facility's Certified Dietary Manager was unable to provide documentation of any hand hygiene training conducted after November 2023.
Why Handwashing Between Glove Changes Matters
Gloves are not a substitute for handwashing. When kitchen workers touch contaminated surfaces — trash cans, soiled dishes, or unwashed countertops — bacteria transfer to their hands. Simply pulling on a fresh pair of gloves over unwashed hands does not eliminate those pathogens. Microscopic tears in gloves, common during food preparation tasks, can allow bacteria to pass directly onto food.
For nursing home residents, the consequences of foodborne illness are far more severe than for the general population. Older adults, particularly those with chronic conditions, weakened immune systems, or who are receiving subacute care, face significantly higher rates of hospitalization and death from pathogens such as Salmonella, Listeria, and E. coli. The Centers for Disease Control and Prevention identifies adults aged 65 and older as one of the groups most vulnerable to serious foodborne illness complications, including kidney failure, bloodstream infections, and death.
The fact that all 122 residents at St Edna consumed food prepared in this kitchen means every resident was potentially exposed to these unsafe handling practices on a daily basis.
Improper Food Cooling Procedures
Beyond handwashing failures, inspectors found that two of the facility's cooks did not properly monitor or demonstrate knowledge of cool-down procedures for TCS (time/temperature control for safety) foods.
TCS foods — which include cooked meats, dairy products, cooked rice, and cut fruits and vegetables — must be cooled from 135°F to 70°F within two hours, and then from 70°F to 41°F within an additional four hours, according to the FDA Food Code. This two-stage cooling process exists because the temperature range between 41°F and 135°F is known as the "danger zone," where bacteria can double in number every 20 minutes.
When kitchen staff are not competent in monitoring this process, food can remain in the danger zone long enough for bacterial populations to reach levels capable of causing illness. For a facility serving pureed and modified-texture diets to residents with swallowing difficulties, the risk is compounded — these foods have more surface area exposed to potential contamination.
Unsanitized Prep Surfaces and Dishwashing Failures
Inspectors also documented that one cook failed to sanitize food preparation surfaces, a basic step in preventing cross-contamination between raw and cooked foods, or between allergens and allergen-free meals.
Perhaps most concerning from a systemic standpoint, one dietary aide was unable to demonstrate three fundamental dishwashing competencies:
- Knowledge of the correct rinse cycle temperature for the dish machine - How to test the sanitizing solution of the dish machine according to manufacturer guidelines - How to test the sanitizing solution of the manual ware-washing sink according to manufacturer guidelines
These are not advanced skills. They are baseline competencies that any kitchen employee handling dishwashing duties should be able to demonstrate. The inability to verify that dishes are being properly sanitized means the facility could not ensure that plates, utensils, and cups returned to residents were free of harmful bacteria.
A review of the dietary aide's employee file revealed no job description on record, despite the employee having been hired in January 2024 — approximately five months before the inspection. The absence of a job description raises questions about what training and performance standards the employee was held to.
What Proper Protocols Require
Under federal regulations (F-Tag 802), nursing homes must provide sufficient support personnel who are competent to safely and effectively carry out food and nutrition services. This means not only having enough staff, but ensuring each employee can demonstrate proficiency in:
- Hand hygiene procedures, including when and how to wash hands - Temperature monitoring for cooking, holding, and cooling foods - Sanitization of surfaces, equipment, and dishware - Safe food handling to prevent cross-contamination
The facility's Registered Dietitian confirmed during an interview on June 20, 2024 that employees are required to wash their hands between glove changes — acknowledging the standard that multiple staff members were observed violating.
New Administrator, Ongoing Gaps
When inspectors interviewed the facility's Administrator on June 20, 2024, he stated he had been working at St Edna for only three months. He described the facility's quality oversight as including monthly kitchen audits by the Registered Dietitian, annual employee evaluations, and meetings through the QAPI (Quality Assessment and Performance Improvement) program.
However, the inspection findings suggest these oversight mechanisms were not effectively identifying or correcting the food safety deficiencies. The most recent documented handwashing training occurred in November 2023 — more than seven months before the inspection — and at least one employee hired after that date had no record of receiving such training at all.
The gap between the facility's stated quality assurance processes and the conditions observed during the survey points to a breakdown in supervision and accountability within the dietary department.
122 Residents at Potential Risk
The deficiency was classified at a level of minimal harm or potential for actual harm, affecting some residents. While no specific illnesses were documented during the survey period, the pattern of violations represents ongoing risk rather than an isolated incident.
Food safety failures in institutional kitchens are cumulative. Each instance of improper handwashing, each batch of food cooled outside of safe parameters, and each inadequately sanitized dish adds to the probability that a vulnerable resident will eventually be exposed to a harmful pathogen. In a population where the average resident may have multiple comorbidities and reduced ability to fight infection, even a single foodborne illness event can lead to hospitalization or worse.
St Edna Subacute and Rehabilitation Center is required to submit a plan of correction addressing each cited deficiency. For complete details on all findings from the June 2024 federal health inspection, readers can review the full survey report through the Centers for Medicare & Medicaid Services.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St Edna Subacute and Rehabilitation Center from 2024-06-21 including all violations, facility responses, and corrective action plans.
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