COMER, GA - Federal inspectors documented multiple violations at Comer Health and Rehabilitation during a January 16, 2025 inspection, citing the facility for food preparation failures that affected nine residents requiring pureed diets and infection control lapses that compromised clean linen storage.
Dietary Staff Skipped Key Nutritional Ingredients
The most significant violation involved dietary staff improperly preparing pureed foods for residents with swallowing difficulties. During the inspection, surveyors observed a dietary employee preparing pureed carrots for nine residents by adding only water and thickener to the puree machine, omitting the low-sodium chicken base required by the facility's own recipe.
The dietary worker told inspectors he "did not use vegetable broth when preparing puree and wasn't sure if they had any vegetable broth." According to the facility's recipe for Carrots Herb Pureed Thick, low-sodium chicken base should have been used to ensure proper consistency and nutritional value.
Pureed diets are prescribed for residents with dysphagia or swallowing disorders, conditions common in nursing home populations. These modified diets must maintain nutritional density while achieving safe texture consistency. When dietary staff omit prescribed ingredients like broths or bases, the resulting meals can lack essential nutrients, flavor, and proper consistency.
The Dietary Kitchen Manager confirmed during the inspection that the dietary employee "should have used broth when mixing the pureed carrots to give it flavor." The facility's Registered Dietician acknowledged the error and stated she would have staff remove the improperly prepared carrots and add the required broth.
Clean Linen Cart Contaminated with Food Items
Inspectors also documented infection control failures when they discovered an opened bag of chips stored inside a clean linen cart on Hall A. The cart was used for storing both clean linens and personal protective equipment (PPE) gowns for staff use.
When questioned, the Certified Nursing Assistant (CNA) responsible admitted the chips were hers and acknowledged "it was not supposed to be stored on the clean linen cart." The CNA recognized the potential for cross-contamination and resident safety risks from storing food items with clean medical supplies.
Clean linen and PPE storage areas must remain uncontaminated to prevent healthcare-associated infections. Food items can harbor bacteria, particularly when opened and exposed to environmental contaminants. When stored with clean medical supplies, these items can transfer pathogens to materials that directly contact residents.
Infection Control Risks Identified by Staff
The facility's Registered Nurse and Infection Prevention Nurse explained the contamination risks to inspectors, noting that "anyone could have grabbed the food and consumed it, which could lead to infection risks, particularly if the food was contaminated by someone with an infectious condition."
The Director of Nursing expressed concern that food contamination in clean linen carts "could result in the transfer of germs to the linens and PPE, which could negatively impact residents, especially those with open wounds or compromised immune systems."
Healthcare-associated infections represent a significant risk in nursing home settings, where residents often have compromised immune systems, chronic wounds, or medical devices that create infection pathways. Proper storage of clean supplies serves as a critical barrier in preventing pathogen transmission.
Facility Policy Requirements
The facility's own policies outlined standards that were not followed during the inspection. The Menus policy, reviewed on December 29, 2023, specified that "menu items should be nutritionally adequate, attractively served, palatable, at a safe and appetizing temperature."
The facility's Infection Prevention Plan identified goals including preventing "the transmission of infectious and communicable diseases" and preventing "healthcare associated infections." The plan emphasized that "prevention of a spread of infections is accomplished by use of standard precautions and other barriers."
Administrative Response
The facility Administrator confirmed to inspectors that the food storage incident "should not occur" and acknowledged that food in clean linen carts "could contaminate the linens and PPE, posing risks to resident safety." The Administrator noted that CNAs had received in-service training on infection control practices designed to prevent such violations.
Both violations were classified as having "minimal harm or potential for actual harm" by federal inspectors. However, the dietary violation affected nine residents requiring specialized nutrition support, while the infection control lapse had potential facility-wide implications.
Industry Standards for Pureed Diet Preparation
Professional standards for modified texture diets emphasize maintaining nutritional density while achieving appropriate consistency for safe swallowing. The International Dysphagia Diet Standardisation Initiative provides guidelines that require facilities to follow specific recipes and preparation methods to ensure resident safety.
Omitting prescribed ingredients like broths can result in foods that lack proper moisture content, nutritional value, and palatability. These factors can contribute to reduced food intake, weight loss, and malnutrition in vulnerable nursing home populations.
Infection Prevention Best Practices
Healthcare facility infection control standards require strict separation of clean and contaminated areas. Clean linen storage must be protected from environmental contamination through proper storage methods, staff training, and regular monitoring.
The Centers for Disease Control and Prevention recommends that healthcare facilities maintain dedicated storage areas for clean supplies, implement staff education programs, and conduct regular audits to ensure compliance with infection prevention protocols.
Comer Health and Rehabilitation operates a 76-bed facility serving residents with various medical conditions, including hospice and dialysis patients who may be particularly vulnerable to nutrition deficiencies and healthcare-associated infections.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Comer Health and Rehabilitation from 2025-01-16 including all violations, facility responses, and corrective action plans.
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