YOUNTVILLE, CA - Federal inspectors documented multiple food safety violations at Veterans Home of California-Yountville during a March 2025 inspection, finding meals served at dangerously low temperatures and widespread failures in infection control protocols that put 144 elderly residents at risk.
Dangerously Cold Food Temperatures Documented
Inspectors found the facility's rethermalization system failing to properly heat food before serving to residents. During test observations, pureed chicken measured just 116.6 degrees Fahrenheit and mashed potatoes reached only 109.4 degrees F - far below the required 165 degrees F minimum temperature for hot food service.
Food service staff acknowledged the violations when temperatures were measured. "The pureed chicken and mashed potatoes were just barely warm when tasted," inspectors noted. The Food Service Supervisor confirmed that vegetables "had no flavor" and chicken "was a little dry" during taste testing.
The facility's monitoring system proved inadequate, with staff testing temperatures on only one cart out of five during each meal service. Multiple carts were allowed to leave the kitchen with food temperatures ranging from 127 to 155 degrees F - all below safe serving temperatures.
Federal food safety standards require hot food to reach 165 degrees F to eliminate harmful bacteria that can cause foodborne illness. Serving food below this temperature creates conditions where pathogens like Salmonella and E. coli can survive and multiply, potentially causing severe gastrointestinal illness in vulnerable elderly residents.
Kitchen Equipment and Hygiene Violations
Inspectors documented contaminated equipment throughout the main kitchen facility. An industrial can opener showed "orange and black, sticky residue" on its blade that transferred to paper towels when wiped. Staff confirmed the equipment "was supposed to be cleaned after each use" but acknowledged it was not clean.
Three air vents in food preparation areas displayed "black, fuzzy substance resembling dust" spreading across vent covers and extending down walls onto clean equipment storage areas. Food service management admitted the vents needed cleaning but had no scheduled maintenance program in place.
A Food Service Supervisor was observed working without proper hair restraint coverage for facial hair, violating basic food safety protocols designed to prevent contamination during food handling.
Infection Control Failures Across Multiple Departments
The facility demonstrated systematic failures in infection prevention protocols that could facilitate disease transmission among residents. Staff consistently failed to follow hand hygiene requirements and proper use of personal protective equipment.
Enhanced Barrier Precautions Not Followed
Three residents requiring Enhanced Barrier Precautions for medical devices received improper care. Nursing staff failed to wear required gowns and gloves when administering medications through feeding tubes and providing catheter care, despite clear signage indicating the requirements.
One resident with a gastrostomy tube told inspectors: "The nursing staff have not been wearing gowns for this. I know it is for my safety that they do."
Improper Cleaning Procedures
Housekeeping staff used inappropriate cleaning products and methods that could spread contamination rather than prevent it. One custodian used the same mop to clean both bathroom floors and resident room floors, then moved between multiple rooms without changing gloves or performing hand hygiene.
The custodian used only floor cleaner - not disinfectant - to clean bathroom surfaces, creating conditions where harmful bacteria could persist and spread. Facility policy required use of bleach solutions for disinfection, but staff were not following established protocols.
Sterile Technique Violations in Medical Procedures
A registered nurse violated sterile technique requirements while flushing a resident's nephrostomy tube - a procedure requiring strict sterile protocols since the tube connects directly to the kidney. The nurse contaminated sterile gloves by handling non-sterile supplies, then proceeded with the procedure that could introduce infection directly into the resident's urinary system.
Nephrostomy tube infections can lead to serious kidney infections and sepsis, particularly dangerous for elderly residents with compromised immune systems.
Medication Documentation Failures
Staff failed to properly document medication administration for at least one resident with multiple chronic conditions including diabetes, hypertension, and heart disease. A nurse admitted to forgetting to initial the medication record after giving evening medications, creating potential for dangerous dosing errors.
"It was an omission that placed Resident 57 at risk for a medication dosing error if not identified by night shift," the nurse acknowledged during interviews.
Equipment Maintenance Issues
Inspectors found a walk-in freezer with extensive ice buildup measuring over 24 inches long, 18 inches wide, and 2 inches thick covering both ceiling areas and food storage boxes. The ice formation indicated equipment malfunction that could compromise food quality and safety.
The facility's dietary director confirmed freezers must be maintained free of ice buildup, but management was unaware of the extensive accumulation affecting food storage conditions.
Impact on Resident Safety
These violations collectively created multiple pathways for foodborne illness and infection transmission among the facility's vulnerable elderly population. Inadequate food temperatures, contaminated equipment, and failed infection controls represent serious threats to resident health and safety.
The documented failures occurred across all departments - food service, nursing, housekeeping, and maintenance - indicating systemic problems with safety culture and oversight rather than isolated incidents.
Federal regulations require nursing facilities to maintain comprehensive infection control programs and ensure food safety to protect resident health. The violations at Veterans Home California-Yountville demonstrate failures in these fundamental safety requirements that put elderly veterans at unnecessary risk.
The facility must develop comprehensive corrective action plans addressing staff training, equipment maintenance, and monitoring systems to prevent future safety failures and protect resident welfare.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Veterans Home of California - Yountville - Snf from 2025-03-07 including all violations, facility responses, and corrective action plans.
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