Federal meat inspectors documented black mold, water dripping over meat and dead flies at a Virginia Boar’s Head deli meat plant that has now been linked to nine deaths from listeria, according to records.
Over the course of a year, food safety inspectors, who are a constant presence in meat facilities across the United States, noted escalating problems at the plant.
Under U.S. Department of Agriculture rules, the processing facility, in rural Virginia, was expected to swab for listeria, which the agency considers a “zero tolerance” concern that can spur an immediate recall. Yet the inspectors — who also swab and test for listeria, a lethal bacteria — do not appear to have been the first to prompt a recall of more than seven million pounds of ham, salami, hot dogs and other meats by Boar’s Head.
The alarm rang after people like Günter Morgenstein, a hair stylist renowned in coastal Virginia, fell gravely ill. As Mr. Morgenstein, an active 88-year-old known as Garshon, grew frail in the hospital in early July, his family racked their brains to think of everything he had eaten in recent weeks.
As listeria illnesses spread, a disease detective in Maryland began to suspect liverwurst as the common thread, given the older age of the hospitalized patients. Her hunch proved correct: Whole genome sequencing matched the patients’ bacteria to Boar’s Head liverwurst bought at a store, according to the Centers for Disease Control and Prevention, setting off the recall of 3,500 tons of meat.
At the same time, U.S.D.A. inspectors documented flies, bits of meat on food-contact surfaces and mold on a wall at the Boar’s Head plant in Jarratt, Va. From June 2023 through this August, inspectors listed 84 problems at the facility. Listeria was not mentioned in more 80 pages of inspection records on the plant that were released by the agency.
“Clearly there’s a breakdown in the process when you have a zero-tolerance policy but you still see listeria and deaths as well,” said Brian Ronholm, who is the director of food policy for Consumer Reports, a watchdog group, and a former food safety official at the U.S.D.A. Under the policy, ready-to-eat food discovered by a company or the U.S.D.A. to be contaminated with listeria is to be destroyed and recalled.
A spokeswoman for the Agriculture Department said that the Virginia facility has been closed until it “is able to demonstrate it can produce safe product.”
The spokeswoman said that Boar’s Head had corrected problems at the plant that were cited by inspectors. The U.S.D.A. said the facility was inspected by the Virginia Department of Agriculture and Consumer Services, which did not respond to requests for comment.
Liverwurst from the Jarratt Boar’s Head plant was first recalled on July 25, and then the company expanded the recall on July 29 to include all the meat processed there.
In an email, a spokeswoman said the company leaders “deeply regret” the impact the outbreak has had on the families of those affected and on its customers. The company provided a full list of the more than 50 meats that were recalled, but emphasized that listeria had been found on only liverwurst samples connected to the Jarratt plant.
Boar’s Head said it was working with top food safety experts to determine the cause of the problem, which it said was “limited to a single process” at the plant in Virginia, one of several the company operates.
On Thursday, a company spokeswoman said: “We want to assure consumers that no product will be released from this facility until it meets the highest quality and safety standards that you deserve and expect.”
The C.D.C. said 57 people, ranging in age from 32 to 95, had been hospitalized, but added that many more likely became ill and had recovered without testing for listeria. The nine people who died were all older than 70, according to the agency.
Health experts have expressed concerns that consumers may still have recalled products, some of which do not expire before October, in their refrigerators. And they advised consumers and retailers to clean surfaces where the deli meats had contact, because listeria can linger stubbornly on counters, deli slicers and other places and is not killed by refrigeration.
Some people also may not experience symptoms, which can include vomiting and diarrhea, until weeks after they’ve consumed contaminated products.
Food safety experts who reviewed the inspection reports said that they were troubling, given the repeated nature of problems, including dripping or standing water that can foster an environment where listeria bacteria thrive.
In October 2023, an inspector noted plastic wrapped around an overhead pipe outside a cooler with “orange/brown water” pooled in the lowest hanging point. “The establishment typically does this for temporary fixes,” the inspection report said.
In February, an inspector noted “ample amounts of blood in puddles on the floor” and “a rancid smell in the cooler.” In June, 15 to 20 flies were seeing going in and out of vats of pickles.
“Considering there’s continuous inspection, it’s a real mystery why it ever got so bad before it got to this,” said Neal Fortin, the director of the Institute for Food Laws & Regulations at Michigan State University.
Concern about listeria has been so high that the U.S.D.A. has devised rules specifically aimed at limiting spread of the lethal pathogen in ready-to-eat food, such as deli meat.
In a guideline in 2012, the U.S.D.A. said about 1,500 hospitalizations and 250 deaths each year were linked to listeria. The bacteria is particularly deadly to people who are very young, older than 65 or pregnant, according to the C.D.C.
Past outbreaks have been severe and led to some criminal prosecution. Thirty-three people died in a listeria outbreak in 2011 tied to cantaloupe, one of the deadliest outbreaks in recent history. Two cantaloupe farmers were sentenced to five years’ probation for their involvement in the case.
Blue Bell Creameries paid $17.25 million in criminal penalties after a 2015 listeria outbreak linked to its contaminated ice cream killed three people. Blue Bell’s former chief executive pleaded guilty to one misdemeanor charge and paid a $100,000 fine.
Mr. Fortin said the U.S.D.A. listeria rules allow food companies to choose one of three methods to control listeria. Records from the department show that the Virginia Boar’s Head plant relied on a system based on keeping a sanitary plant and routine testing to monitor for the bacteria. Other options include taking measures to kill listeria or prevent it from growing on the meat.
The option Boar’s Head used in Virginia “is the least reliable and it’s the hardest to do,” Mr. Fortin said. “I won’t buy lunch meat from anyone who uses” that method.
The Virginia facility was required to do environmental testing, Mr. Fortin said, which could mean swabbing drains, walls, floors or food-cutting surfaces. If listeria is found, companies are expected to sanitize thoroughly and then test the finished product to ensure it is free of bacteria.
Any discovery of listeria in food is a serious matter, Mr. Fortin said, leading to an immediate recall. Generally, though, he said facilities have no day-to-day duty to test products.
Exactly how the Virginia facility carried out its listeria safety plan — or whether it had turned up any positive swabs — remains unclear. The U.S.D.A. did not respond to specific questions about testing for listeria.
Spreadsheets posted on the department’s website that list listeria test results of thousands of samples taken by officials at many facilities showed negative results at the Boar’s Head Virginia plant in January 2016 and in September 2021. The facility is not listed on a summary of test results released in 2024.
Mr. Morgenstein’s family said he was fond of Boar’s Head liverwurst as a comfort food eaten on a plain bagel. It reminded him of his childhood in Germany, which he fled as a child to escape Nazi rule. A receipt from Harris Teeter provided by Ron Simon, his family’s lawyer, shows he made the purchase on June 30.
“Garshon’s three favorite things were honey ham, lox and liverwurst,” his wife, Peggy Morgenstein, said. Even at 88, he was still cutting customers’ hair three days a week.
Over the course of his 10-day hospital stay, Mr. Morgenstein weakened and became feverish. As the bacteria reached his brain, he grew uncharacteristically irritable, his wife said. Hospital staff had to put mittens on him to keep him from pulling at his tubes. Then he fell quiet.
Mr. Morgenstein died on July 18 of listeria-related brain swelling, his death certificate shows. Had there been a warning about the recall, Ms. Morgenstein said her family would have known.
“My husband and I are news freaks,” she said. “We certainly wouldn’t have bought it if we had seen that.”
In the week after Mr. Morgenstein died, epidemiologists in Maryland began noticing that the people who had fallen ill with listeria in their state all skewed older; they were, on average, 76.
Health officials suspected that the meat to blame might be popular among older generations, said Dr. Sinisa Urban, head of the environmental sciences division at the Maryland Department of Health.
On July 18, the local investigators bought a package of Boar’s Head liverwurst from a major grocery chain in Baltimore and, in a turn of luck that Dr. Urban believes probably saved lives, the first package of liverwurst tested positive for the bacteria when definitive results arrived a week later.
“This is a very rare instance where things lined up very, very quickly,” he said. “It’s like finding a needle in a haystack.”
Given the seriousness of the outbreak, more answers are needed, and are expected to emerge in the coming weeks, said James Dickson, a food safety expert at Iowa State University.
“It doesn’t help the people who got sick, it doesn’t help the people who died,” he said. “But hopefully down the road we learn something from this so it doesn’t happen again.”
