The food safety violations discovered during a February inspection affected 55 of the facility's 59 residents who receive oral diets. Federal inspectors also found the nursing home had no water management program, despite facility policy requiring one as part of infection control.
During a February 18 kitchen tour that began at 9:15 a.m., inspectors documented multiple violations in the walk-in freezer. A sleeve of waffles sat on a shelf without any date marking. The half-bag of onion rings remained open in a box with no identification. Most concerning was a five-pound box of frozen fish sticks that had been opened and not resealed.
Two additional open containers held sausage and frozen eggs, neither properly labeled or dated.
The facility's own policy, titled Food Receiving and Storage and dated November 2022, explicitly states that "all foods stored in the refrigerator or freezer are covered, labeled and dated." The policy requires refrigerated foods to be "labeled, dated and monitored so they are used by their use-by date, frozen or discarded."
When inspectors returned the next morning at 9:30 a.m. for a second observation, the unlabeled and improperly stored items had been removed. The box of fish sticks was discarded because staff couldn't determine its use-by date.
The Dietary Kitchen Manager, interviewed on February 20 at 10:45 a.m., acknowledged that kitchen staff were expected to label and date each food item received by the facility. She said it was her expectation for staff members to properly store food items after opening them.
The manager told inspectors she would implement a daily double-checking system to ensure food safety going forward.
The second violation involved the complete absence of a water management program. The facility's Infection Prevention and Control Program policy, revised in October 2022, clearly states under section 16 that "a water management program has been established as part of the overall infection prevention and control program."
No such program existed.
The Administrator confirmed during a February 20 interview at 1:40 p.m. that the facility lacked an established Water Management Plan. He revealed he had identified this deficiency when he started working at the facility two weeks earlier and added it to the agenda for the next Quality Assurance Performance Improvement meeting scheduled for March.
The Administrator said daily hot water temperature checks would become part of the future Water Management Plan.
Hill Haven Nursing Home, located at 880 Ridgeway Road in Commerce, serves 59 residents. The food safety violations had the potential to expose the vast majority of residents to foodborne illness from improperly stored and undated items.
Federal regulations require nursing homes to procure food from approved sources and store, prepare, distribute and serve food according to professional standards. The violations documented at Hill Haven represent failures in basic food safety protocols that protect vulnerable elderly residents from contamination and spoilage.
The infection control violation affects all residents in the facility. Water management programs are designed to prevent the growth and spread of Legionella and other waterborne pathogens in healthcare facilities. Without proper monitoring and control measures, residents face increased risk of serious respiratory infections.
Both violations were classified as causing minimal harm or potential for actual harm. However, the scope affected either many residents in the case of food safety or all residents regarding water management.
The facility's policies existed on paper but weren't implemented in practice. Kitchen staff ignored labeling and dating requirements despite clear written procedures. The water management program existed as a policy statement but had never been established as an actual operational program.
The Administrator's acknowledgment that he discovered the water management issue within two weeks of starting work suggests the violation had persisted under previous leadership. His plan to address it through the March quality improvement meeting indicates the facility recognized the seriousness of the deficiency.
The food safety problems appeared to be resolved quickly once inspectors identified them. The removal of unlabeled items and disposal of the undated fish sticks demonstrated the facility could correct violations when they were brought to staff attention.
However, the Dietary Kitchen Manager's promise to implement daily double-checking suggests the violations resulted from inadequate supervision rather than staff ignorance of proper procedures. The facility's own policies clearly outlined the requirements that kitchen staff had failed to follow.
The inspection occurred on February 20, 2025, as part of routine federal oversight of nursing home operations. Both violations must be corrected and plans of correction submitted to state survey agencies.
Hill Haven's residents depend on staff to follow basic safety protocols that prevent foodborne illness and waterborne infections. The documented failures in both areas represent breakdowns in fundamental care standards that put vulnerable residents at unnecessary risk.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hill Haven Nursing Home from 2025-02-20 including all violations, facility responses, and corrective action plans.