Deficiencies in Food Safety and Maintenance Practices
Summary
The facility failed to maintain proper temperature logs for their refrigeration units, as observed during a kitchen tour. The temperature logs for the walk-in refrigerator and freezer were incomplete, with several days missing records. The Director of Dietary (DOD) indicated that the cook was responsible for recording these temperatures but had not done so due to being absent. Additionally, the milk refrigerator and ice cream freezer logs were also incomplete, with numerous instances of missing temperature recordings. This lack of documentation was attributed to dietary aides not fulfilling their responsibilities. The facility also failed to address maintenance issues with the walk-in freezer, which had a significant frost buildup. The DOD and the Director of Maintenance were aware of the problem, which persisted even after a new door was installed. The Director of Maintenance had not successfully contacted the company responsible for the door installation to address the issue, leading to continued frost accumulation. This issue was known for several months, but no effective action was taken until prompted by the surveyor's inquiry. Furthermore, the facility did not adhere to proper food labeling and storage practices. Observations revealed that prepared food items in the walk-in refrigerator were not labeled or dated, and some items were not discarded after the recommended three-day period. Personal items were improperly stored in the kitchen area, and dietary staff did not consistently wear beard guards while preparing food. Additionally, expired food items were found in the resident nourishment refrigerator, and the facility failed to record food temperatures before serving, as required by their policy.
Penalty
Resources
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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 multiple food safety violations involving improper storage, labeling, dating, and temperature control of food items in the main kitchen, adjacent kitchenette, and a therapy gym refrigerator/freezer used for resident food. Numerous items, including dried onion flakes, tortillas, milkshakes, lettuce, cheese, hamburgers, lunchmeats, chicken fingers, juices, strawberries, and baked goods, were observed unsealed, open to air, spoiled, expired, or lacking required labels and dates. A freezer used to store juices and baked goods was operating at 48°F despite product instructions requiring temperatures below 38°F, and the Administrator was unaware that food and beverages were being stored in that malfunctioning unit. In the therapy area, resident food items such as meat, crackers, a premade salad, a partially consumed milkshake, and ice cream were also found open, unnamed, and undated, with both the DM and Therapy Manager confirming these items were not in compliance and should have been discarded.
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.
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.
Improper Food Storage, Labeling, and Temperature Control in Dietary and Therapy Areas
Penalty
Summary
Surveyors identified a deficiency related to food safety and storage practices in the facility’s dietary and ancillary food storage areas, affecting all 69 residents who received food from the kitchen. During observations, an unsealed, open-to-air bag of dried onion flakes was found, and the Dietary Manager (DM) confirmed it was not properly sealed and should have been discarded. In stand-up freezer #1, surveyors observed an undated, open bag of flour tortillas and an undated, unlabeled milkshake, which the DM acknowledged were not dated, not properly sealed, and should have been discarded. In a kitchenette refrigerator next to the main kitchen, surveyors found visibly spoiled lettuce, a package of cheese, and a box of hamburgers, all unlabeled and undated; the DM confirmed these items should have been discarded. In stand-up refrigerator #1, a bag of turkey lunchmeat and a bag of ham lunchmeat were found unsealed and open to air, and the DM again confirmed they were not properly sealed and should have been discarded. Further observations showed additional food safety issues. Stand-up freezer #2 contained two thermometers reading 48°F while storing individually packaged orange, prune, and apple juices labeled to be kept below 38°F, along with boxes of individually wrapped dinner rolls and doughnuts; the DM confirmed the elevated temperature and that the juices’ storage instructions required temperatures below 38°F. The Administrator later confirmed awareness that the freezer was under consideration for repair or replacement but was unaware that food and beverages were being stored in it. In stand-up refrigerator #4, an unsealed bag of cheese and a bag of thawed frozen strawberries dated as opened on 03/07/26 were found, and the DM confirmed the cheese was not properly sealed and the strawberries had expired. In freezer #3, a bag of chicken fingers was found unsealed and open to air, which the DM stated should have been discarded. In the therapy gym refrigerator and freezer used to store resident food, surveyors found meat and crackers labeled only with a resident name but undated, a premade salad in a takeout container unnamed and undated, a partially consumed milkshake open to air with no name or date, and an opened, unnamed, undated half-gallon container of vanilla ice cream; the Therapy Manager confirmed these items were not properly labeled and dated and should have been discarded.
Plan Of Correction
F 0812 F 0812 No resident experienced negative effects related to the unsealed box of dried onion flakes observed on 03/23/2026 @ 09:21 am. No resident experienced negative effects related to the undated bag of flour tortillas that were open-to-air and undated, observed in stand-up freezer #1 on 03/23/2026 @ 09:23 am. No resident experienced negative effects related to the undated and unlabeled milkshake that was observed in stand-up freezer #1 on 03/23/2026 @ 09:23 am. No resident experienced negative effects related to the unlabeled and undated visibly spoiled lettuce, package of cheese, and box of hamburgers observed in the kitchenette next to the main kitchen refrigerator on 03/23/2026 @ 09:27 am. No resident experienced negative effects related to the unsealed and open-to-air bag of turkey lunchmeat and bag of ham lunchmeat observed in stand-up refrigerator #1 on 03/23/2026 @ 09:39 am. No resident experienced negative effects related to the individually packaged servings of orange juice, prune juice, and apple juice; as well as individually wrapped dinner rolls and doughnuts observed in stand-up freezer #2 which contained two thermometers reading 48 degrees Fahrenheit, on 03/23/2026 @ 09:42 am. No resident experienced negative effects related to the unsealed bag of cheese and gag of thawed frozen strawberries with an open date of 03/07/2026, observed in the stand-up refrigerator #4, on 03/23/2026 @ 09:39 am. No resident experienced negative effects related to the unsealed bag of chicken fingers observed in freezer #3 on 03/23/2026 @ 09:50 am. No resident experienced negative effects related to the labeled [R] [R] meat & crackers which was undated; and a premade salad in a takeout container unnamed and undated, observed in the therapy gym refrigerator on 03/26/2026 @ 12:16 pm. No resident experienced negative effects related to the partially consumed milkshake that was open-to-air with no name of date and a half-gallon container of vanilla ice cream that was opened, unnamed and undated, observed in the therapy gym freezer. LNHA notified Medical Director on 04/06/2026 of the findings noted during Annual Survey that involved inappropriately stored foods/drinks and that no negative effects were identified in any resident related to the inappropriately stored foods/drinks. No new orders were received from Medical Director. LNHA/Designee will educate licensed and unlicensed personnel in the following: §483.60(i)(1)(2) Food Procurement, Store/Prepare/Serve-Sanitary §483.60(i) Food safety requirements. The facility must - §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. LNHA/Designee will complete daily rounds, observing food storage areas, ensuring that all items are labelled, dated, unexpired, and stored appropriately (i.e., appropriate temperature levels in refrigerators (<41 degrees Fahrenheit), freezers (at or below 0 degrees Fahrenheit). Issues will be addressed upon recognition of issue. Also, LNHA/Designee educated Dietary Manager & Therapy Director on 03/26/2026 that staff foods/drinks must be stored in separate refrigerators/freezers than residents. Further, all items in the resident's refrigerators/freezers must be dated/labeled and expiration date(s) observed. Any expired, unlabeled, or undated items are to be discarded straight away. Dietary Manager also educated on 03/26/2026 that refrigerators storing food and beverages must meet the temperature threshold of <41 degrees Fahrenheit (refrigerator) or 0 degrees or less (freezer). Freezer that was being utilized as a refrigerator was removed from service on 03/26/2026. Juices were moved to an actual storage refrigerator, within acceptable temperature range. There is adequate storage space for refrigerated and frozen items, so replacement of malfunctioning freezer is not necessary, but on or before 04/30/2026, the interdisciplinary team (IDT) will meet and discuss benefits of purchasing a new refrigerator/freezer and determine necessity. If necessary, quotes will be obtained by LNHA and purchase made. Dietary Staff will observe & record refrigerator and freezer temperatures every shift, at least twice daily to ensure temperatures are within acceptable limits (refrigerator < 41 degrees Fahrenheit and freezer at or below 0 degrees Fahrenheit). Any failing equipment will be removed from service immediately and reported to Maintenance for corrective action. Dietary Manager will be responsible for ensuring this occurs. Compliance will be determined by daily review of Dietary staff documentation by Dietary Manager. Dietary Manager audited refrigerators located in the kitchen, kitchenette, and Therapy gym on 03/26/2026. Undated, unlabeled, and expired items were discarded. Dietary Manager also verified that all refrigerators and freezers in use in the kitchen, kitchenette, and Therapy gym were within appropriate temperature range(s) (< 41 degrees refrigerator & at or below 0 freezer) on 03/26/2026. LNHA/Designee will complete audits that determine if foods & drinks are being appropriately stored and that Dietary staff are consistently and appropriately monitoring refrigerator and freezer temperatures (below 41 degrees Fahrenheit). Inappropriately stored items will be addressed straight away. These audits will be completed on at least 3 refrigerators/freezers every week x4; then as determined by QAA.
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.
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