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 true, but they 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 under-reporting 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 across the country. With this wave of seniors have 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 found that residents nationwide are at risk for foodborne illness from unsafe kitchens, as detailed in inspection reports, federal data and interviews with residents and long-term care experts.
Across the country, 230 foodborne 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 — figures experts say are almost certainly an undercount.
While foodborne illness is a threat to any age group, people over 65 are especially susceptible due to weakened immune systems, chronic diseases, immobility and age-related changes in their digestive systems.
Yet unlike restaurant patrons, who can walk away from bad meals — and trash the establishment later on Yelp — long-term care residents are basically stuck.
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 Dec. 6, 2018, inspection report. Investigators found that the kitchen staff had failed to monitor and control sanitizer levels in the dishwasher. The facility’s administrator did not return phone calls or email for comment.
A foodborne illness outbreak swept through a rural California nursing home in the fall of 2014, sickening 16 residents, after a dietary aide who prepared each person’s plate came to work while ill, and the kitchen sink lacked sufficiently hot water, according to state public health documents. One resident, who died of sepsis during that time, tested positive for salmonella. The Wish-I-Ah nursing home near Fresno was voluntarily closed that year by its owner, Brius Healthcare Services of Los Angeles, amid state accusations of widespread unsanitary conditions and poor quality care. A company lawyer and spokesman declined to comment.
Dangerous food handling common
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.
In 2018, 33 percent of nursing homes were cited for violating the federal requirement to safely store, prepare and serve food.
Several of the largest nursing home chains had even worse track records, federal data show.
Genesis HealthCare, the nation’s largest for-profit chain, saw more than 43 percent of its nursing homes cited for food safety lapses last year. The chain, based in in Kennett Square, Pennsylvania, has about 400 facilities in 27 states.
“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 nonprofit and for-profit facilities for the elderly and disabled.
“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.
Feds propose rollback
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.
Existing regulations require that a director of food and nutrition services meet educational requirements or certifications. Under the new proposal, a director who has been doing the job for “several years” could continue to do so, getting “frequently scheduled consultations” from a dietitian or other nutrition professional.
In comments recently submitted to the government, many described the plan as risky, “absurd” and “a step backwards in healthcare.”
“The thought of allowing people to run the kitchens without proper training or education is nothing but scary,” read one comment.
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.
The true extent of foodborne illnesses and deaths in long-term care is unknown because the CDC data doesn’t capture every incident. 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.
A 2015 report by the nonprofit Center for Science in the Public Interest found that states vary widely in how well they detect and report foodborne illnesses, and that lack of funding for public health services may play a role.
Not all foodborne illnesses are directly caused by poor sanitation. Some outbreaks result from contaminated food brought in from the outside.
But many problems originate from within.
Nursing home inspection reports, available online, are filled with stomach-churning details. Page after page describe a chronic lack of hand-washing; months-old expired food; workers handling raw meat with bare hands, then touching residents’ food and utensils; microwaves and stovetops caked with debris.
However, of the 5,621 citations last year for food safety lapses, only 25 — less than 1 percent — were deemed serious enough to warrant a high-level citation. Nursing home violations are known as “deficiencies” and, typically, only those deemed serious will trigger fines.
“By treating life-threatening conditions (in the kitchen) as minor problems, regulators are sending a message to nursing home operators that no change is needed,” said Michael Connors of California Advocates for Nursing Home Reform, a San Francisco-based nonprofit.
A spokeswoman for the Centers for Medicare & Medicaid Services explained in an email that “multiple factors are considered” in imposing fines or other enforcement actions. In weighing penalties, she said, the government considers the level of harm and number of residents affected.
Like many advocates, Connors believes much of the blame lies with operators who are so intent on increasing profits that they routinely skimp on residents’ dietary needs, or slash kitchen staff.
Turnover is high and pay is low for kitchen workers, even though a single slip-up can sicken dozens of residents at once.
Few outsiders, including family members, ever see the food preparation areas. Elder-care advocates, who routinely visit nursing homes to troubleshoot residents’ complaints, admit they rarely set foot in the kitchen or peek inside the pantry.
Harrington, the UC San Francisco professor, said that unless government inspectors find “obvious” harm to a patient — a foodborne outbreak, for instance — they will continue writing low-level citations for chronic, unsanitary conditions.
“This is why a nursing home has no incentive to clean things up,” Harrington said. “It’s horrible. It’s not like these residents can go out and get food somewhere else.”
Serial offenders called "disgraceful"
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 nursing home data.
During that period, 1,553 nursing homes — 10 percent — were cited three or more times for the same failure.
Gifford noted that repeat citations may result from different problems covered by the same food safety regulation.
Mollot, of the New York-based Long Term Care Community Coalition, described these repeat offenders as “disgraceful.”
“These are things they can easily fix,” he said. “The problems are just so basic. We know how to have a sanitary kitchen.”
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, official 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.
“No,” the nurse responded, according to the inspection report.
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.
Oversight varies among states
America’s shifting demographics suggest that many more elderly people will be at risk as they pour into long-term care in coming years. The number of Americans over age 65 is projected to grow from 47.8 million in 2015 to nearly 88 million in 2050, the U.S. Census Bureau reports.
In the United States, about 1.3 million residents were living in nursing homes in 2016 and more than 800,000 were in assisted living or similar residential care communities, according to the National Center for Health Statistics.
Nursing homes, which care for people 24/7 with severe medical conditions, are regulated by both the federal and state governments. As recipients of taxpayer money, they have uniform federal requirements, with accountability data made available to the public.
Assisted living communities house people who can no longer live independently but don’t need around-the-clock nursing care. Proliferating nationwide, these facilities lack federal oversight and are licensed by the states, which create their own standards.
In both settings, inspection practices vary widely across the country, FairWarning found in a nationwide survey of state health departments.
“It varies so much — the quality of your care and oversight depends on your zip code,”said Robyn Grant of the National Consumer Voice for Quality Long-Term Care.
In April, Seema Verma, administrator of the Centers for Medicare & Medicaid Services, acknowledged in a blog post that widespread inconsistencies among states still exist when determining citations.
Expertise among inspectors also differs dramatically.
Many states still rely almost exclusively on nurses to evaluate long-term care kitchens and identify risks. But a handful of states — Michigan, Colorado and Georgia, among them — involve trained food safety specialists in these inspections.
Colorado recently revised its system after conducting an extensive study that revealed troubling food safety conditions in 150 nursing homes and assisted living facilities in that state. The 2016 study found that the long-term care kitchens had significantly higher rates of food violations than restaurants and other institutions, including jails and schools — and that nurse-inspectors were routinely overlooking critical problems while focusing instead on more minor matters.
Assisted living lacks federal scrutiny
Food safety experts fear that problems may be worse in assisted living centers, which lack federal oversight and range in size from a handful of residents to hundreds. Some offer special memory care units for those with dementia or Alzheimer’s Disease.
“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 long-term care residents.
Said Grant: “I’ve heard assisted living described as the wild wild West under a roof, and it does feel that way.”
In Northern California, four elderly people died in November 2012 after eating poisonous mushroom gravy at a six-person assisted living home near Sacramento. The caregiver, who also got sick, had accidentally picked toxic wild mushrooms in the home’s backyard to prepare the meal.
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, and a complaint was filed with the Department of Social Services. “It’s not right,” Kelly said. “It was really, really disgusting.”
Cockroaches are known to carry salmonella and contaminate food.
She said that 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.”
Treating kitchens like restaurants
Some states are making changes in their inspection practices, ranging from posting placards with 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 were less vital to residents’ safety.
“What happens is, your real food safety — your real foodborne risk factors — can get out of control, because people are so concerned about all these other little things,” said Therese Pilonetti of the Colorado Division of Environmental Health & Sustainability, who worked on the pioneering study.
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. The specialist has taken over the role once performed by nurses.
The federal government only requires that inspection teams include a registered nurse. A spokeswoman for the Centers for Medicare & Medicaid Services said that states have the discretion to select team members from a variety of professions, but they are expected to have the “needed skills to effectively perform surveys.”
Similar to Colorado, Michigan is tapping into food safety specialists to evaluate its nursing home kitchens by adding sanitarians to the actual survey team.
Federal data show that Michigan levied the highest number of fines last year for food safety violations, and collected the most money at more than $3 million.
California authorities last year temporarily closed the kitchens of three nursing homes 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 one 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.”