This article was produced by FairWarning, a nonprofit news organization based in Southern California that focuses on public health, consumer and environmental issues.
Flies buzzing the undercooked hamburgers. Cockroaches scurrying for cover behind the oven. A moldy ice machine. Mystery debris, clinging to the crevices of a meat slicer. Hundreds of mouse droppings, trailing across the hood of the stove.
These incidents are not logged in any restaurant inspector’s notebook. They are among the thousands of food safety violations discovered in the last three years in America’s nursing homes, where fragile residents can least tolerate such lapses.
While allegations of elder abuse and neglect dominate the horror stories in long-term care settings — bedsores, falls, medication errors, sexual assaults — food handling remains a consistent and often overlooked hazard, FairWarning found in a five-month investigation.
“There’s huge underreporting of food issues,” said Charlene Harrington, a nurse and professor at the University of California, San Francisco, who has researched nursing home quality.
“It’s an accepted practice to have crappy conditions in the kitchen,” she said. “And people are just totally unaware of it.”
As America’s population ages, hundreds of thousands of baby boomers have found their way into nursing homes, assisted living communities and memory care units. With this wave of seniors has come new dining demands, a culinary call that has been answered in some places with gourmet chefs, a panoply of fresh fruits and vegetables and other healthy flourishes.
But dangerous and unhealthy conditions persist.
FairWarning’s investigation, based on inspection reports, federal data and interviews with residents and long-term care experts, found that residents nationwide are at risk for foodborne illness from unsafe kitchens.
Across the country, 230 foodborne illness outbreaks were reported from 1998 to 2017 in long-term care settings, according to the Centers for Disease Control and Prevention. The outbreaks resulted in 54 deaths and 532 hospitalizations, and sickened 7,648 people.
Not all foodborne illnesses in long-term care are directly caused by poor sanitation; some outbreaks result from contaminated food brought in from the outside.
But critical internal mistakes have happened. Last year, 29 residents and 32 staff members at the Pine View Care Center in Black River Falls, Wisconsin, were sickened in a norovirus outbreak, according to the government’s inspection report. Investigators found that kitchen staff had repeatedly failed to check the sanitizer levels in the dishwasher and didn’t know the injector was clogged, the report said. The facility’s administrator did not return phone calls or email for comment.
Unsafe food handling was the third most frequently cited violation last year inside America’s estimated 15,700 nursing homes, behind only infection control and accidents, according to data from the Centers for Medicare & Medicaid Services, which regulates nursing homes that receive federal money. These figures do not include assisted living communities, which have no nationwide centralized data collection and are licensed by the states, which create their own standards.
Several of the largest nursing home chains had even worse track records, federal data show.
Genesis HealthCare, the nation’s largest for-profit chain with some 400 facilities in 27 states, saw more than 43 percent of its nursing homes cited for food safety lapses last year. “We are aware of some regulatory compliance issues and are working diligently to resolve any problems as quickly as possible,” Genesis spokeswoman Lori Mayer said in an email.
Dr. David Gifford, a senior vice president and chief medical officer of the trade group for long-term care providers, defended the industry’s handling of food safety in an email to FairWarning.
“Because long-term care providers take many steps to prevent outbreaks of foodborne illness, such outbreaks are rare,” said Gifford of the American Health Care Association, which represents more than 13,500 nonproft and for-profit facilities for the elderly and disabled.
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“The vast majority of issues identified during inspections are important to correct but are rated by the state and federal officials as unlikely to put anyone’s health at significant risk.” Examples of less critical offenses that can result in citations, he wrote, include things like staff members failing to wear gloves, a bearded worker without a face guard or unlabeled leftovers.
The true extent of foodborne illnesses and deaths in long-term care is unknown, since the CDC data is almost certainly an undercount.
A CDC spokesman said the agency relies on the voluntary reporting of foodborne illness outbreaks by state, local and territorial public health departments, and that some of these agencies have limited resources and training. Another “major limitation” in the data collection is that many illnesses go unreported because the sick individuals never seek medical care and get diagnosed, he said.
And federal safeguards for this vulnerable population may be eroding.
In July, the Trump administration moved to roll back a series of protections for nursing home residents, including one proposal that would lower the qualifications for directors of food and nutrition services. The government contends that the changes would eliminate requirements that are “unnecessary, obsolete or excessively burdensome.”
“They’re clearly weakening the standards regarding food service and the safety of food handling,” said Richard Mollot, executive director of the New York-based Long Term Care Community Coalition, a nonprofit focused on improving care in nursing homes and other residential settings.
Gifford, of the trade association, argues that the changes would address “workforce concerns, particularly in rural areas,” by allowing facilities to retain “qualified” staff who have worked there for years.
Long-term care advocates blame many food safety problems on operators who are so intent on increasing profits that they routinely skimp on residents’ dietary needs, or slash kitchen staff.
Some nursing homes violate the same food safety rule again and again. Since January 2016, about a third of all nursing homes were cited two or more times for the same food safety violation, according to a FairWarning analysis of federal data.
Gifford noted that repeat citations may result from the array of issues that fall under the same food safety regulation.
FairWarning’s analysis found that one Arkansas nursing home was written up seven times in the last three years, receiving a single fine of less than $8,000. Violations at The Waters of North Little Rock, previously known as the North Little Rock Health and Rehabilitation Center, included unsealed foods in storage, grimy kitchen appliances and staff with unwashed hands touching residents’ food, inspection reports show.
When the nursing home was cited a sixth time in July 2018, a government inspector asked the director of nursing if she would eat the food prepared in the kitchen.
The 140-bed facility changed ownership early this year, public documents show, and its current administrator, Spencer Rogers, told FairWarning the food safety problems have been corrected, although the home was cited again in April for unwashed hands, expired food and dirty equipment. The home previously was owned by New Jersey-based Skyline Health Care, a chain that recently collapsed, leaving a multistate trail of nursing home closures, dislocated residents and damning inspection reports.
The founder, Joseph Schwartz, could not be reached for comment.
Food safety experts fear that problems may be worse in assisted living centers, which lack federal oversight.
“I’ve seen horrible stuff — bugs crawling in food, rodents actually in the pantries — it’s just horrific, especially when you get into some of these smaller assisted living facilities that are just barely keeping it together,” said Brian Lee, executive director of Families for Better Care, a Texas-based nonprofit that advocates for residents in long-term care.
Audrey Kelly of Los Angeles said she quickly moved her 98-year-old mother out of a six-person assisted living facility this year after a caregiver reported finding a cockroach in the kitchen and a complaint was filed with the California Department of Social Services. “It’s not right,” Kelly said. “It was really, really disgusting.”
She said her mother, Sally Kelly, who uses a wheelchair after several strokes, became ill several times during her stay at the Toluca Lake Manor Senior Assisted Living home in Sherman Oaks, California, suffering from severe stomach cramps and diarrhea, though the cause of the symptoms is unclear.
The state, which did not find roaches in a follow-up visit, substantiated Kelly’s complaint anyway and cited the home. The home’s administrator, Mariana Romano, told FairWarning she promptly reported Kelly’s complaint to state officials and brought in two extermination companies. She denied to state officials that she had any pest problems. “You can say anything,” Romano said. “It doesn’t mean it’s true.”
One Georgia woman, who lives in an assisted living facility near Atlanta where rooms cost thousands of dollars a month, said she has experienced several bouts of food-related illness that confined her to bed. Residents recently were upset by moldy cheese and wilted lettuce that appeared on the salad bar.
“It was just horrible,” said the woman, who asked not to be identified for fear of reprisal.
“You wonder why a lot of residents here have stomach problems, or their health goes down quickly.”
Some states are making changes, ranging from posting placards with inspection grades to including food safety experts on inspection teams.
In Colorado, health officials were alarmed by their 2016 study showing that long-term care homes in the state had higher rates of food safety violations than restaurants and other retail food establishments — sometimes up to 30 times higher.
The study noted that nurses leading the survey teams tended to call out violations that were highly visible — missing hairnets, for instance, or chips in the tile — but less vital to residents’ safety.
The study found that a trained food safety specialist was more likely to zero in on critical practices, such as hand-washing, heating and cooling of food, and handling of raw meat. Last year, the state received grant money to hire a dedicated food safety expert to begin kitchen inspections in all 270 assisted living kitchens with 20 or more residents.
Similarly, Michigan is tapping food safety specialists, such as sanitarians, to help evaluate nursing home kitchens, even though the federal government only requires that inspection teams include a registered nurse.
Last year, Michigan levied the highest number of fines for federal food safety violations of any state, and collected the most money, more than $3 million, data show.
States also have shut down nursing home food operations because of safety problems. In California, at least three nursing homes had their kitchens temporarily closed last year because of unsafe conditions. The homes were forced to bring in restaurant food for residents, or cut a deal with nearby establishments to supply meals.
Two of the homes in Southern California had cockroach infestations, while inspectors at a third facility in the San Francisco Bay Area discovered numerous dead flies and the “strong smell of feces and sewage” inside the kitchen.
“If you were to go take those exact same problems and stick them in a Taco Bell or a Bob Evans, you would never eat there again,” said Lee, of Families for Better Care.
“There would be such a public outcry to get those restaurants closed. And they would be closed, because nobody would go there again.”