Improper Food Storage and Preparation
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety, as observed during a survey. The deficiency was identified when ground beef and frozen shelled eggs were found to be improperly thawed and stored at unsafe temperatures. Specifically, the ground beef was measured at 71 degrees Fahrenheit, which is within the danger zone for food temperatures, and the eggs were previously frozen and cracked, posing a risk for bacterial growth. These items were intended for use in preparing a meatloaf meal for residents. The issue arose due to malfunctioning refrigeration equipment. The facility's walk-in refrigerator had been non-functional for over a year and was being used to store pantry items instead. A second walk-in refrigerator also failed, leading staff to use a temporary break room refrigerator, which was not maintaining safe temperatures. The temporary refrigerator was found to be at 54 degrees Fahrenheit, and the ground beef inside was at 71 degrees Fahrenheit. Staff were observed defrosting food items at room temperature, which is against safe food handling practices. Interviews with staff revealed a lack of awareness and adherence to proper food safety protocols. The kitchen staff admitted to not maintaining temperature logs for the temporary refrigerator and were unaware of when the ground beef was placed inside. The facility's Food Service Supervisor (FSS) and Administrator decided to cater meals after the surveyor's intervention, acknowledging the risk of foodborne illnesses from the improperly stored and thawed food items. The facility's policy on food preparation and service, which prohibits thawing at room temperature and requires maintaining food temperatures outside the danger zone, was not followed, leading to the deficiency.
Removal Plan
- No contaminated foods were prepared or provided to any residents. Food was discarded immediately upon observation of incorrect temperature.
- Industrial refrigeration was ordered.
- A refrigeration truck was ordered for cold storage.
- Food truck delivered.
- The physician was notified of the alleged deficiency. There were no new orders obtained.
- [NAME] was educated and suspended pending investigation.
- Dietary Staff has been educated on food temperatures, preparation, and service for all residents.
- Dietary Staff will notify the Administrator immediately if an occurrence of incorrect temperatures or questions/issues regarding food service and will follow procedures.
- Procedures include checking refrigerator temperatures daily, following policy and procedures for Food Preparation and Service.
- Interventions set in place to include catered food for residents for 3 meals per day.
- Contact and notification for recommendations from RD E.
- RNC assessed all residents in facility for any GI symptoms including nausea, vomiting, diarrhea. No symptoms noted.
- Ad-Hoc QAPI meeting was held with the Medical Director, NHA, RDO and Marketing Director, LVN to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy.
- Administrator completed 1:1 in-service with Dietary Manager on Food Preparation and Service policy.
- Staff educated by administrator on Food Preparation and Service policy.
- Dietary manager in-serviced by Registered dietician [RD H]. RD also in-service dietary staff as well.
- Facility leadership will complete education with all staff on Food Preparation and Service, to ensure that each resident receives the services consistent with the professional standards of practice, comprehensive person-centered care plan and the residents' goals and preferences, keep residents safe.
- The training was initiated and will be completed. Staff will not be allowed to work until they receive training.
- The policy pertaining to Food Preparation and Services was reviewed by the NHA, Marketing Director, LVN, DON, RDO, and Medical Director.
- IDT, including Administrator, DON, Activity Director, Marketing Director, HR, BOM will meet daily after rounds Monday to Friday, and Manager on Duty Saturday and Sunday to determine if any Kitchen refrigerators or temperatures were out of appropriate range.
- The findings will be immediately brought to the Administrator for further action, if necessary.
- Grievances will be reviewed during morning meetings with Administrator and IDT team members for any follow-up needed.
- All grievances will be entered into the Grievance Log by Administrator and investigation form will be filled out accordingly.
- Administrator will monitor kitchen daily by doing rounds during business days for any change in kitchen refrigerator temperatures she will monitor on weekend days for one month and then random audits will be provided thereafter.
- An audit sheet of rounding will be kept in a binder specified for follow up.
- Admin or designee will conduct audits for daily rounds for one month then periodically thereafter.
- Administrator will be notified by staff of any issues noted in the dietary department.
- Administrator will monitor refrigerator temperatures daily during business days and weekend manager will monitor on weekends for appropriate functioning and temperature utilizing a thermometer placed in refrigerator.
- RDO will provide physical oversight at facility weekly and then random reviews after.
- The RDO will provide oversight of the Administrator to ensure the items on the removal plan are reviewed and completed.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
Surveyors found that kitchen sanitation and milk handling practices were deficient. An uncovered, overflowing trash can was located next to a food prep area where a dietary aide was portioning fruit. Staff did not consistently monitor milk temperatures, and milk was sometimes served above the 41°F guideline despite a policy requiring cold potentially hazardous foods to be held at or below that temperature. Temperature logs showed many meals without recorded milk temperatures, and expired milk cartons remained in the milk chest, with expired milk served to a resident.
Surveyors identified that the facility did not maintain clean and sanitary kitchen conditions or proper food storage for residents receiving meals. Two dietary staff serving breakfast had full beards without beard coverings, and equipment such as a floor‑stand mixer, stove shelf, and nearby walls had visible food splatter, grease, dust, and residue. An unlabeled and undated bag of vanilla wafers was found in dry storage, and the walk‑in refrigerator had a ripped, moldy gasket. The dish area had missing floor tiles. These conditions were inconsistent with the facility’s written policy requiring all food preparation and service areas to be kept clean and sanitary.
Surveyors found that kitchen staff failed to maintain sanitary food storage and preparation conditions and did not ensure proper equipment and food temperatures for residents served from one house kitchen. Inspectors observed uncovered and undated food items in the refrigerator and freezer, dirty wash cloths stored next to food, and brown residue on the pantry freezer and cabinets holding cooking equipment and utensils. The dishwasher was operating below required wash and rinse temperatures, hot food (sausage) was held below the facility’s policy standard of 135°F, and a CNA cooked eggs and bacon on an electric skillet without wearing a hair net.
Surveyors found that the facility failed to maintain sanitary conditions in the kitchen, where food was prepared and served for all residents receiving meal trays. Observations on multiple days showed a convection oven, stove, and areas under the steam and tray lines with food splatter, crumbs, and debris; walls behind equipment with dust, dirt, and dried food; a hanging electrical outlet and an air conditioning unit with built-up dust; and uncovered trash cans near the oven and in the dishwashing area. These conditions were confirmed with the dietary manager and did not comply with the facility’s policy requiring all equipment to be kept clean and sanitary.
Surveyors found that the facility failed to keep kitchen equipment and food service areas clean and sanitary and did not follow its own sanitation procedures. During observations, they noted dried food in a microwave, crumbs on prep surfaces, undated cereal containers, rusty refrigerator shelves, unlabeled and improperly wrapped butter and cheese, grease and food splatter on serving equipment, and dried food in multiple steam table wells and lids. The dish area had cracked floor tiles and dried food on the clean side of the dish machine drain board, while the cooking area contained a slicer with dried meat, a robot coupe with dried food around its base, and damaged tiles and a wall hole where food carts were stored. A dietary staff member was also seen rinsing the robot coupe in a three-compartment sink without proper wash and sanitize steps, despite policies and checklists requiring thorough cleaning and proper wrapping, labeling, and dating of food.
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Maintain Sanitary Food Service and Proper Milk Handling
Penalty
Summary
The facility failed to store, prepare, and serve food under sanitary conditions, affecting the entire census of 86 residents. Surveyors observed that a large garbage can located near a prep table and three-compartment sink in the kitchen did not have a lid and was repeatedly overflowing with trash, including large cans piled above the rim, on multiple observations over two days. During one observation, a dietary aide was portioning pineapple into cups and covering them with plastic wrap on the prep table adjacent to the uncovered, overflowing trash can. The dietary manager confirmed that the garbage can was not covered with a lid. Surveyors also found that milk temperatures were not consistently monitored and that milk was not always maintained at or below the facility’s policy guideline of 41°F. During a supper tray line, milk temperatures were not initially taken, and when requested, a milk sample measured 40°F. On another meal service, pre-poured milk cups were left on the three-compartment sink before being placed in the milk chest, and later a glass of milk taken from the chest measured 46.9°F; staff confirmed that milk temperatures were not obtained before the tray line started. Review of March food temperature logs showed that milk temperatures were missing for 47 of 71 meals, and the dietary manager acknowledged inconsistent monitoring. Additionally, surveyors found multiple cartons of 1% milk in the milk chest past their use-by date, and a staff member reported using two expired cartons for resident trays, with one expired milk serving provided to a resident. The facility’s written policy required potentially hazardous cold foods to be kept at or below 41°F and verified with a clean, sanitized, and calibrated thermometer.
Unsanitary Kitchen Conditions and Improper Food Storage
Penalty
Summary
Surveyors found that the facility failed to maintain the kitchen in a clean and sanitary manner and to store food to prevent contamination and spoilage for 47 of 48 residents who received food, with one resident identified as NPO. During a kitchen tour, two dietary staff members serving breakfast were observed to have full beards without beard coverings. The floor‑stand mixer had food splatter on the backsplash, white mix on top, and dried food residue on the stand. In the dry storeroom, a bag of vanilla wafers was found open without any label or date. The walk‑in refrigerator had a ripped gasket with mold present. In the cooking area, the stove shelf had grease, dust, and food residue, the wall near the microwave had food splatter, and there were grease drippings on the stove. In the dishwashing area, floor tiles were missing. The dietary staff member interviewed confirmed these observations. Review of the facility’s kitchen sanitation policy, titled “Environment” and revised in June 2015, stated that all food preparation, service, and dining areas would be maintained in a clean and sanitary condition, which was not followed as evidenced by the unsanitary conditions and improper food storage identified during the survey conducted under Complaint Number 2693841.
Failure to Maintain Sanitary Food Storage, Preparation, and Safe Temperatures in House Kitchen
Penalty
Summary
Surveyors identified a deficiency in food storage, preparation, and sanitation practices in House Five’s kitchen affecting 21 residents who received food from that kitchen. Observation of the refrigerator showed an undated and uncovered pitcher of pink liquid and a piece of cardboard from a drink box used to hold the water dispenser shut. The freezer contained two undated medical ice packs, two undated gallon bags of ice with ice crystals, and an undated, open loaf of gluten-free bread exposed to air. In the pantry, a bucket full of dirty wash cloths was stored next to a shelf holding potatoes, and the pantry freezer and multiple cabinets and drawers (including those containing a crock pot, skillet, mixing bowl, cutting board, and measuring cups) had a brown substance on them. The dietary technician present confirmed these observations. Further observations showed the House Five kitchen dishwasher was operating below required sanitizing temperatures, with a wash temperature of 148°F and a rinse temperature of 175°F, which the dietary technician acknowledged were below the expected 160°F wash and 180°F rinse. During meal service, a CNA measured sausage being held at 127.6°F, below the facility’s policy requirement that hot foods be maintained at 135°F or higher, and confirmed this temperature. On another observation of meal preparation, a CNA was cooking eggs and bacon on an electric skillet without wearing a hair net, despite having her hair in a ponytail, and confirmed she was not wearing a hair net. These conditions collectively demonstrated failure to store and prepare food in a sanitary manner, to ensure proper dishwasher temperatures, and to maintain hot foods at safe holding temperatures for residents served from House Five’s kitchen.
Unsanitary Kitchen Conditions During Food Preparation and Service
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to prepare and serve food under sanitary conditions for all 92 residents receiving trays from the kitchen. On 03/17/2026 at 10:33 A.M., observation of the kitchen revealed a convection oven with food splatter and crumbs, a container under the steam table with food debris, a wall behind the plate warmer with dust and dirt buildup, and a wall behind the toaster table with dried food splatter. On 03/18/2026 at 2:20 P.M., further observation with the Dietary Manager showed a hanging electrical outlet over the serving line and an air conditioning unit with built-up dust, uncovered trash cans beside the convection oven and in the dishwashing area, a stove with dried food debris and splatter, and a shelf under the tray line with crumbs and food debris. These conditions were verified with the Dietary Manager and were inconsistent with the facility’s Sanitary Conditions policy stating that all equipment will be maintained in a clean and sanitary fashion. The deficiency had the potential to affect all 92 residents who receive food from the kitchen and was investigated under Complaint Number 2696142. No specific residents, medical histories, or clinical conditions were described in the report beyond the census count and the fact that 92 residents receive trays from the kitchen.
Failure to Maintain Sanitary Kitchen Conditions and Follow Food Service Sanitation Procedures
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain the kitchen in a clean and sanitary condition and to follow its own sanitation policies. During an early morning kitchen tour, they observed dried food inside a microwave and food crumbs on the table beneath it, as well as undated containers of various cereals on a shelf. In a reach-in refrigerator, five shelves were rusty, shredded cheese was not labeled or dated, and butter stored in a hotel pan was not properly wrapped, labeled, or dated. In the serving area, there was grease on the table under the toaster, food splatter on the plate warmer and pellet warmer, and dried food in seven of ten steam table wells with five dirty lids containing dried food and gravy. In the dish area, floor tiles were cracked, and the clean side of the dish machine drain board had dried food and a salt packet on it. In the cooking area, the slicer had dried meat near the blade, the robot coupe had dried food around its base, and there were cracked tiles and a hole in the wall where food carts were stored. These conditions were verified by a staff member. Further observation showed that a dietary staff member rinsed the robot coupe in the three-compartment sink without following proper washing and sanitizing procedures, stating that she only rinses it out. Review of the facility’s “Operation and Sanitation” policy indicated that operating instructions and cleaning procedures are developed for all dining services equipment, and the closing checklist required that all equipment be cleaned and all food wrapped, labeled, and dated. The facility’s failure to follow these established procedures and checklists resulted in multiple areas and pieces of equipment in the kitchen not being properly cleaned, sanitized, labeled, or maintained, affecting food storage, preparation, and service for nearly all residents who received meals from the kitchen.
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