ARLINGTON, VA - Federal inspectors cited Cherrydale Health and Rehabilitation Center for multiple violations including improper glucose meter disinfection that posed immediate danger to residents and widespread food safety failures affecting the majority of residents.
Immediate Jeopardy Cited for Blood Sugar Testing Procedures
The most serious violation at Cherrydale Health and Rehabilitation Center involved the improper disinfection of glucose meters used for blood sugar testing, resulting in an immediate jeopardy citation that posed direct risk to resident safety. Federal inspectors observed nursing staff using the same glucose meter on multiple diabetic residents without proper disinfection between uses.
During the April 22 inspection, surveyors witnessed a registered nurse obtain blood sugar readings from two residents within minutes of each other using the same glucometer without disinfecting the device between uses. When the nurse finally cleaned the meter with a germicidal wipe, she failed to allow adequate drying time before returning it to storage.
The violation affected multiple residents with diabetes who required regular blood glucose monitoring. The facility's own policy required glucometers to be cleaned according to manufacturer recommendations, and the device manual specifically called for germicidal wipe disinfection between each patient use. However, staff were inconsistently using alcohol wipes instead of the required germicidal disinfectant.
Medical Context: Bloodborne Pathogen Risks
Proper disinfection of glucose meters is critical because the devices come into contact with blood during fingerstick testing. When meters are not adequately disinfected between residents, they can transmit serious bloodborne infections including hepatitis B, hepatitis C, and HIV. The lancets used to prick fingers create small wounds that can harbor infectious agents, making thorough disinfection essential.
Healthcare facilities must follow strict protocols for point-of-care testing devices. The Centers for Disease Control and Prevention requires that all blood glucose meters be cleaned and disinfected with EPA-approved germicidal wipes after each use, with specific contact times to ensure pathogens are eliminated. Alcohol wipes, while useful for cleaning, do not provide the antimicrobial action needed to kill bloodborne viruses and bacteria.
The immediate jeopardy determination reflected the serious nature of this violation. Federal regulators reserve this classification for situations where facility practices pose immediate risk of serious injury, harm, impairment, or death to residents. The facility was required to implement emergency corrective measures and demonstrate compliance before the citation could be removed.
Widespread Food Temperature Failures Compromise Nutrition
Inspectors documented systematic failures in maintaining proper food temperatures, with seven residents specifically complaining during a resident council meeting that their meals were consistently served cold. Temperature testing revealed dramatic drops between food preparation and delivery to residents.
When corporate dietitians tested food temperatures at the serving line, items registered at appropriate levels: turkey meatloaf at 150°F, mashed potatoes at 145°F, and corn at 158°F. However, by the time the same test tray reached residents approximately 35 minutes later, all temperatures had dropped significantly - with the meatloaf, potatoes, and corn all measuring around 103-104°F.
The facility's registered dietitian, who worked at a sister facility, acknowledged she had not conducted test trays at Cherrydale to verify food temperatures and had not implemented interventions to address ongoing resident complaints about cold food. When asked about policies regarding food palatability, the dietitian stated no such policy existed at the facility.
Medical Impact of Inadequate Food Temperatures
Proper food temperature serves multiple critical functions in healthcare settings. Foods served below 140°F enter the "danger zone" where harmful bacteria can multiply rapidly, increasing foodborne illness risk. For elderly residents with compromised immune systems, foodborne illnesses can lead to serious complications including dehydration, hospitalization, and even death.
Beyond safety concerns, cold food significantly impacts nutritional intake among elderly residents. Research shows that food temperature directly affects appetite and consumption patterns in older adults. When meals are served cold, residents are less likely to consume adequate calories and nutrients, potentially leading to malnutrition and weight loss. For residents already at nutritional risk due to medical conditions, medication side effects, or swallowing difficulties, consistently cold meals can accelerate nutritional decline.
The facility should have implemented temperature monitoring protocols, insulated food transport systems, and timing procedures to ensure meals maintain safe and appetizing temperatures from kitchen to resident. Standard practice requires hot foods to be maintained at or above 140°F during transport and service.
Beverage Service Failures Affect Hydration Goals
Inspectors found systematic failures in providing beverages as specified on residents' meal plans, with 12 residents consistently not receiving milk with their meals despite meal tickets indicating milk should be included. The violations occurred on multiple days and affected residents eating in both the dining room and their individual rooms.
One resident specifically told inspectors that meal tickets didn't always match what appeared on trays and that items were frequently missing. When staff checked the resident's meal ticket after he mentioned missing milk, they confirmed he should have received 2% milk and had to retrieve it from the dining room. The resident noted he didn't always drink milk but wanted the option since it was listed on his meal plan.
A corporate registered dietitian present during one meal service directed kitchen staff to ensure the 12 affected residents received their milk, acknowledging there was no reason residents weren't served milk since it was available and clearly listed on both the menu and individual meal slips.
Hydration and Nutritional Considerations
Adequate fluid intake is particularly critical for nursing home residents, who face increased dehydration risks due to age-related changes in kidney function, medications that affect fluid balance, and reduced thirst sensation. Milk provides not only hydration but also important nutrients including protein, calcium, and vitamins essential for bone health and overall nutrition.
For residents with specific dietary needs or medical conditions, prescribed beverages may serve therapeutic purposes. Diabetic residents may receive specific types of milk to help manage blood sugar levels, while those with kidney disease may have carefully calculated fluid allowances. When prescribed beverages are omitted, it can disrupt carefully planned nutritional interventions and compromise health outcomes.
Healthcare facilities are required to honor residents' food and beverage preferences while meeting their nutritional needs. The failure to provide beverages as specified on meal plans represents both a service failure and a potential nutritional deficit that could impact resident health over time.
Food Storage Violations Create Contamination Risks
The facility failed to properly date, label, and store food products throughout the kitchen and storage areas, potentially affecting all 185 residents who consume facility-prepared meals. Inspectors found bread products stored in open containers without dates or labels, and bulk rice stored in opened bags without proper dating or labeling.
During the kitchen inspection, surveyors observed dinner rolls in open plastic bags inside cardboard boxes, exposed to air and completely unlabeled. Crescent rolls were wrapped in plastic but lacked dates and labels. In the dry goods storage room, multiple varieties of rice were stored in large, opened paper bags without any dating system.
The facility's registered dietitian confirmed these storage practices violated food safety protocols and acknowledged there was no schedule for checking food dates or removing expired products. The facility's own policy required food to be stored in ways that maintain quality and safety, with proper dating using a first-in, first-out system.
Food Safety and Contamination Prevention
Proper food labeling and dating systems are fundamental to preventing foodborne illness in healthcare settings. When foods lack dates, staff cannot determine freshness or safety, potentially leading to service of spoiled or contaminated products. Open storage containers allow contamination from pests, airborne bacteria, and cross-contamination from other foods.
The "first in, first out" principle ensures older products are used before newer ones, preventing accumulation of expired foods. Without systematic dating and rotation, facilities risk serving foods past their peak quality or safety period. For vulnerable elderly residents with compromised immune systems, consuming spoiled or contaminated foods can result in serious gastrointestinal illnesses requiring hospitalization.
Industry standards require all opened food products to be dated, labeled, and stored in closed containers to maintain freshness and prevent contamination. Regular inventory checks should identify and remove expired products before they can be inadvertently served to residents.
Additional Issues Identified
Inspectors also documented the facility's lack of comprehensive policies for food palatability and temperature monitoring. The registered dietitian confirmed no formal procedures existed for conducting test trays or addressing resident food complaints, representing gaps in quality assurance processes.
The facility was required to develop and implement immediate corrective action plans for all identified violations, with ongoing monitoring to ensure sustained compliance with federal regulations designed to protect resident health and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cherrydale Health and Rehabilitation Center from 2025-04-24 including all violations, facility responses, and corrective action plans.
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