Kitchen Sanitation Deficiency
Summary
The facility failed to maintain the kitchen food service areas and equipment in a clean and sanitary condition, which could potentially lead to cross-contamination and food-borne illness affecting all 76 residents. During an initial tour of the kitchen, a commercial table-mounted can opener was found with a build-up of a grease-like substance, metal fragments, and rust. The blade of the can opener was missing silver laminate, exposing bare metal and rust. The Dietary Manager confirmed these observations and acknowledged the need for cleaning before further use. Additionally, the range hood filters above the cooking surfaces were covered in a dark and light brown grease-like substance with dust-like strands hanging over the cooking areas. The Dietary Manager admitted that the cleaning service, which cleans the filters every three months, would need to increase the frequency of cleaning. Further inspection revealed that the 15-foot-long metal food preparation table had caulking at the wall junction embedded with brown and black sticky, food-like substances. The caulking had crusted food particles, which the Dietary Manager confirmed could contaminate food preparation areas. The three-well sink area had a windowsill with a significant build-up of dust and grease, and the window frame above had rust and chipped paint. The ceiling above the clean dish racks also had chipped paint and cobwebs. The facility's policy stated that stove hoods and filters should be cleaned monthly, but the current condition indicated a failure to adhere to this schedule, as confirmed by the Dietary Manager.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Dietary staff failed to follow sanitary practices during meal preparation and service, including not wearing beard guards, not taking holding temperatures before serving, using the same gloves to handle multiple items and surfaces, directly handling food without utensils, and serving food on wet plates. These actions did not comply with facility policies for food safety and staff hygiene.
Staff were observed hand drying meal trays and placing them on the tray line before serving meals to residents. The trays, which should have been air dried to prevent contamination, were then used to serve food and delivered to resident units. This practice was confirmed by dietary management as not meeting sanitary standards.
Staff failed to maintain sanitary food service practices, including using a dirty floor fan that blew air onto clean dishware, not covering facial hair during food preparation, and not changing gloves between tasks such as handling food and touching unclean surfaces. Management acknowledged these lapses did not meet facility policy.
Staff did not store, label, or distribute food in a sanitary manner, as multiple opened food items in various refrigerators and freezers were found without proper labels or dates. Personal beverages and snacks were stored with facility food, and some containers showed signs of spoilage. The dietary manager was aware of these issues and confirmed that labeling and dating are required for all food items.
Surveyors identified multiple deficiencies in food storage, handling, and hygiene, including failure to discard expired perishable items, improper cleaning of food pans, leaving unused food in an out-of-order refrigerator, inadequate temperature control in refrigeration units, and dietary staff not wearing required beard restraints.
Staff failed to store, prepare, and distribute food in a sanitary manner, including leaving opened and unlabeled food items exposed in coolers and freezers, and stacking wet, unclean pans and trays, contrary to facility policy and federal food safety standards. The dietary manager acknowledged these lapses during surveyor observations.
Failure to Maintain Sanitary Food Preparation and Serving Practices
Penalty
Summary
Facility dietary staff failed to maintain sanitary food preparation and serving practices in the kitchen. During dinner preparation, multiple staff members with facial hair did not wear beard guards, despite being aware of the requirement. Staff also failed to take holding temperatures of food items prior to serving them from the steam table. Throughout the meal service, staff wore the same gloves while serving multiple plates, touched the steam table surface with gloved hands, and then used those same gloves to handle serving utensils and directly pick up baked fish and rolls without using utensils. This resulted in the contamination of serving utensils and glove surfaces. Additionally, one staff member used gloved hands to shape rice after touching the steam table and serving utensils, and food was served on plates that had visible water droplets. Interviews with staff confirmed awareness of the need for beard guards and the risks associated with improper glove use, cross-contamination, and serving food on wet plates. Facility policies reviewed indicated requirements for proper staff attire, hand washing, glove use, temperature monitoring, and appropriate use of serving utensils to prevent cross-contamination. These policies were not followed during the observed meal service.
Unsanitary Food Tray Drying Practices Observed in Kitchen
Penalty
Summary
Facility staff failed to serve food in a sanitary manner in the kitchen. On 09/22/2025, an observation revealed that two dietary staff members, including the acting dietary manager and the district manager for dietary, were hand drying 20 resident meal trays and placing them on the tray line. The kitchen staff then slid these trays down the tray line, placed meals on them, and loaded them into food carts for delivery to the unit floors. During an interview, the district manager for dietary confirmed that the trays should have been air dried to prevent contamination. The executive director, vice president of operations, and regional director of clinical services were informed of these findings, and no further information was provided prior to exit.
Sanitary Food Service Deficiencies in Kitchen Operations
Penalty
Summary
Facility staff failed to maintain sanitary food service practices in the kitchen, as observed during multiple site visits. A floor fan was found on the dish room floor, blowing air across clean plate bases and covers, with visible debris and grease on the fan guard. The dietary manager acknowledged the fan was dirty and removed it after the observation. Additionally, a kitchen aide was seen plating pureed cake and assembling dinner trays without a cover over his mustache and facial hair, contrary to facility policy requiring facial hair to be restrained. The aide confirmed that his mustache should have been covered during food preparation. Further observations revealed a cook wearing gloves while performing multiple tasks, including opening and closing the walk-in refrigerator, wiping hands on a dirty apron, handling resident sandwiches, stacking dinner plates, and plating food, without changing gloves between tasks. The dietary manager confirmed that gloves should be changed between tasks to maintain sanitation. Interviews with dietary management staff indicated awareness of these issues and acknowledged that the observed practices were not sanitary and did not align with facility policy.
Failure to Properly Store and Label Food Items in Kitchen
Penalty
Summary
Facility staff failed to store, label, and distribute food in a sanitary manner in the main kitchen. During a kitchen tour, surveyors observed multiple opened food items in the reach-in refrigerator, walk-in refrigerator, and walk-in freezer without proper labels or dates indicating when they were opened. Personal beverages and snacks were stored alongside facility food items in the reach-in refrigerator. In the walk-in refrigerator, items such as three-bean salad, vanilla pudding, cooked spaghetti noodles, corn, ham slices, mayonnaise, and cottage cheese were found without any labels or open dates. The walk-in freezer contained sandwich meats, meatballs, and peppers also lacking proper labeling. Some containers, such as the one containing ham, showed signs of spoilage, including a film on top of the water. The dietary manager acknowledged awareness of the unlabeled and undated food items and confirmed that all food items are required to be labeled with an open date and a use-by date before storage.
Deficient Food Storage, Handling, and Hygiene Practices in Kitchen
Penalty
Summary
Facility staff failed to store and handle food in accordance with professional standards for food service safety. Surveyors observed multiple issues in the kitchen, including the presence of perishable food items past their best-by dates, such as wilted cilantro and expired sparkling cider, which were not discarded promptly. Food preparation pans were found with visible, crusty residues in the clean dish area, indicating they were not properly cleaned before being stored. Additionally, unused food items from previous meals, such as trays of peaches, salads, and pudding, were left in a refrigerator that had been out of order for a month, and these items were not discarded until prompted by surveyors. Some of these food items were uncovered and improperly stored. Temperature control and food storage practices were also deficient. One refrigerator was observed at 50 degrees with no food inside, while another freezer containing ice cream cups lacked a thermometer and had a case of strawberry ice cream that was soft, melted, and separated, despite temperature logs indicating a safe temperature earlier that day. A large bag of diced chicken in the walk-in freezer was found to be soft and not fully frozen. Furthermore, several male dietary aides were observed working without beard restraints, contrary to professional standards for food safety and hygiene. These deficiencies were observed and discussed with facility leadership during the survey.
Deficient Food Storage and Dishware Handling Practices
Penalty
Summary
Facility staff failed to store, prepare, and distribute food in a sanitary manner in the main kitchen, as observed during a kitchen tour with the dietary manager. In the walk-in cooler, opened bags of green peas were not labeled with open or use-by dates, and some bags were left open to air. The dietary manager acknowledged that bags should be tied and boxes closed, and that dating is important for rotation. In the walk-in freezer, a pan of turkey meatloaf was inadequately covered with saran wrap, leaving food exposed and with ice build-up, and the dietary manager stated it would be discarded. Additional items, such as a bag of bread dough and fish filets, were found with holes or open to air, lacking labels or dates. Sausage patties and bacon were also found exposed and without identification. In the stand-alone coolers, garden salads and pitchers of juice were not labeled or dated, and the dietary manager confirmed the juice had been prepared for the meal. Facility policy and federal food codes require proper labeling, dating, and storage to prevent contamination, which was not followed in these instances. Additionally, staff were observed stacking stainless steel pans and meal trays while still wet, with standing water and moisture present, and significant food residue noted on some trays. The dietary manager confirmed that wet stacking can promote bacterial growth. Facility policy and federal food codes require that dishware be air-dried and properly stored after cleaning and sanitizing, which was not adhered to in this case. These findings were shared with the facility administrator and DON during an end-of-day meeting.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
