Deficiencies in Food Service Safety Standards
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During observations, it was noted that cleaning chemicals, specifically glass cleaner, were improperly stored above a food processor. Additionally, the warewashing area had a spray hose nozzle hanging below the sink flood rim, which was in contact with water, posing a risk of back-siphonage. The facility lacked the correct test papers to accurately measure the concentration of the sanitizing solution, as the available test papers did not show the required range of 150 to 400 parts per million of quaternary ammonium compound, as specified by the sanitizer concentrate label. Furthermore, the deli station's reach-down refrigerator door gasket was split and uncleanable, and various areas, including the underside of the floor mixer and floors under the baker's worktable and sink, were soiled with food particles or dirt. During an interview, the facility's administrator acknowledged the issues identified, including the improper storage of glass cleaner, the absence of appropriate sanitizer test papers, the spray hose's potential for back-siphonage, and the need for cleaning in specific areas.
Plan Of Correction
Plan of Correction: Approved February 24, 2025 F812 (483.60) Spray hose and potential back siphonage issue with hose being too long and resting in standing pot water in pot room. 1. Work order placed by supervisor on duty 1/13/25 asking for shorter spray hose to be installed. Work order (# 5) completed on 1/19, issue permanently fixed. 2. All residents have potential to be affected by this alleged deficient practice. Nutrition Service Leadership will monitor this area to verify that the spray hose length is appropriate to prevent potential back siphonage. 3. Nutrition Services and Facilities team made aware that hose must be short and not rest in water. 4. Scheduled kitchen mock surveys in place to document compliance with spray hose length. If non-compliance is discovered a separate work order will be generated and issued to Facilities. 5. Target date for corrective action was 1/19/25. Director Nutrition Services is the responsible party. F812 (483.60) Deli Cooler Gasket was split and uncleanable. 1. Work order submitted on 1/13/25 requesting gasket replacement. Work order (# 1) completed on 1/18/25. 2. All residents have potential to be affected by this alleged deficient practice. 3. Cooler gasket checks have been added to routine cooler preventive maintenance schedule. Deli cleaning and closing checklist revised to add gasket cleaning. Deli staff will be educated on this revised cleaning list, understanding and awareness will be confirmed via employee sign off on this education. 4. Scheduled kitchen mock surveys in place to document compliance with gaskets in main kitchen, deli and SNF kitchen. If non-compliant gaskets are discovered a separate work order will be generated and issued to Facilities. 5. Target date for corrective action was 1/18/25. Director Nutrition Services is the responsible party. F812 (483.60) Incorrect sanitizer test strips used in ware washing sanitizer sink. 1. Ecolab rep called immediately and delivered a supply of QT-40 test strips in less than one hour. All Qt-10 Test strips on site were immediately discarded. 2. All residents have potential to be affected by this alleged deficient practice. Nutrition Service Leadership will monitor this area to verify that the QT-40 test strips are the only strips available and in use for testing PPM of sanitizing solution. 3. Electronic order guide updated to remove QT-10 and replace with appropriate Qt-40 test strip to help prevent the inappropriate test strip from being ordered. Education developed to include manufacturer recommendations for type of test strip to be used to test sanitizer ppm as well as target ppm range. This education will be provided bi-annually. 4. Routine weekly audits x 90 days to ensure compliance. Scheduled kitchen mock surveys in place to document compliance with use of QT-40 test strips. If non-compliance is discovered, we will retrain and reimplement weekly audits to document compliance. 5. Target date for corrective action was 1/13/25 when all QT-10 were discarded and steps implemented as per above. Director Nutrition Services is the responsible party. F812 (483.60) Chemicals not stored properly. Spray bottle of glass cleaner left on windowsill in food prep area near equipment. 1. Spray bottle in question immediately removed from food prep area and stored properly. Inspection of other areas of kitchen revealed no other non-compliant chem storage issues. Staff working in impacted area made aware of non-compliance and reminded of proper storage. 2. All residents have potential to be affected by this alleged deficient practice. Nutrition Service Leadership will monitor the department for compliance with proper chemical storage. 3. Nutrition Service leadership will provide initial and then bi-annual training on proper storage of chemicals. 4. Routine weekly audits x 90 days to ensure compliance. Scheduled kitchen mock surveys in place to document compliance with use of QT-40 test strips. If non-compliance is discovered, we will retrain and reimplement weekly audits to document compliance. 5. Target date for corrective actions is 90 days from survey. Director Nutrition Services is responsible party. Audits and surveys will be shared with SNF QAPI monthly. F812 (483.60) Underside of the floor mixer, floor under the baker’s worktable and bakers sink were soiled. 1. Area under baker’s worktable and pots sink was swept/cleaned immediately by staff members. Work order # 3 submitted requesting removal of the mixer assembly on the underside of the floor mixer for proper cleaning. 2. All residents have the potential to be impacted by this alleged deficient practice. 3. Daily cleaning and closing checklist to be signed off on daily by staff/leader to ensure floors are appropriately cleaned along with other equipment in this area. Mixing assembly removed at underside of floor mixer and sent for cleaning, sanding, repainting. 4. Any non-compliance found daily during cleaning sign off will be addressed in real time. Trends in non-compliance with specific staff will be reviewed weekly when cleaning lists are reviewed prior to scanning into e-file. Non-compliance will be addressed with retraining and job performance disciplines as warranted. Scheduled kitchen mock surveys in place to document compliance with workstation and mixer cleanliness. 5. Target date for corrective action is 90 days from survey. Director Nutrition Services is the responsible party. Daily cleaning sign off and surveys will be shared with SNF Quality Assurance Performance Improvement monthly meeting.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Unsafe Food Storage and Dishwashing Practices: Surveyors observed dented cans in dry storage, a walk-in freezer at 10 F with ice cream, buns, and popsicles soft or showing signs of melt/refreeze, and a handwashing sink trash can that required hand contact to open. Staff were seen carrying used paper towels across the kitchen to overflowing trash cans, and a Dishwasher moved between dirty and clean dish tasks, handled cigarettes in a puddle, and unloaded clean items without changing gloves or performing hand hygiene. The DON/Administrator and Dietary leadership acknowledged the concerns during interview.
Kitchen staff failed to follow food storage and sanitation standards when unlabeled, undated food items were found in the walk-in freezer and refrigerator, an uncovered garbage can was observed next to the prep table, and a DC was not wearing a hair restraint over his mustache area. Staff interviews confirmed that labeling, dating, covering the garbage can, and wearing hair restraints were expected responsibilities, and facility policies required covered, labeled, and dated refrigerated and frozen foods as well as proper personal cleanliness in food prep areas.
Food storage, labeling, and sanitation practices were not followed in the kitchen. Sanitizer buckets tested outside the manufacturer range, numerous prepared and packaged foods were found unlabeled, missing open or use-by dates, or expired across multiple storage areas, and a cook handled raw chicken with contaminated gloves after touching a speaker without removing the gloves or performing hand hygiene.
Improper Hair Restraints During Food Preparation and Service: Kitchen staff were observed serving and preparing meals without properly covering all hair. One staff member wore a beanie that left braids uncovered while assisting with the noon meal, and another wore a headband with hair uncovered while preparing the noon meal. Interviews confirmed staff understood hair restraints were required to keep hair out of food, and the facility policy required all employees in food prep areas to wear a hairnet or hair covering.
Unsafe food storage was identified in the main kitchen and in 1 of 2 nourishment rooms. The walk-in freezer had no stand-alone thermometer, and the 300 Hall nourishment room freezer registered 30 degrees Fahrenheit with 7 thawed ice cream bars stored inside. The Kitchen Manager acknowledged the missing thermometer and confirmed the thawed items.
Food storage, labeling, and sanitation deficiencies were observed in the kitchen and a serving kitchenette. Undated and unlabeled food items were found in refrigerators and freezers, milk was present past its best-by date, food debris and sticky residue were noted in freezer areas, a ceiling vent was dirty, and cooks with beards were observed without beard nets. The DD verified the findings, and staff stated items past date should be discarded and food items should be labeled and dated when stored.
Unsafe Food Storage and Dishwashing Practices
Penalty
Summary
The facility failed to ensure food was safely stored and prepared and that dishes were sanitarily washed during kitchen operations. On 06/16/2026, surveyors observed the dry storage area with a canned food rack containing one dented can of mandarin oranges and two dented cans of apples. On 06/17/2026, additional observations showed two more dented cans of mandarin oranges in the dry storage can rack, and a dented can of apples was also observed next to the industrial can opener on the prep station. Surveyors also observed multiple sanitation and cross-contamination concerns in the kitchen and dishwashing areas. The kitchen handwashing sink had a trash can with a lid that was not operable by foot, requiring staff to lift the lid by hand to discard used paper towels. Staff M, the Dietary Manager, and Staff O, a Dietary Aid, were observed carrying used paper towels across the kitchen to trash cans near the tray line and prep station, including one overflowing trash can with trash sitting on top of the lid and used paper towels falling out onto the tray line. Staff N, the Dishwasher, was observed handling dirty dishes, moving to the clean dish area, unloading clean dishes, and handling clean silverware without changing gloves, and at one point picked up cigarettes from a puddle in the dishwashing area with gloved hands and then returned to dish duties without a glove change. The walk-in freezer was also observed at 10 degrees Fahrenheit, with items such as single-serve ice cream, hot dog buns, ice cream buckets, and popsicles soft to the touch, not frozen, or showing signs of having melted and refrozen. Staff P, Director of Operations, stated the single-serve ice creams should not have been soft and identified some frozen items as belonging to the activity department. Staff M stated the freezer had not been cooling correctly on 06/17/2026. During interviews, Staff P stated dishwashers should remove gloves, perform hand hygiene, and don new gloves when moving between dirty and clean dishes, and Staff A, the Administrator, stated the facility needed to re-wash all kitchen items to ensure they were not contaminated. The cited regulation was WAC 388-97-1100(3), -2980.
Kitchen Food Storage and Sanitation Failures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During a kitchen tour, surveyors observed an uncovered garbage can next to the food prepping table, and the DC was not wearing a hair restraint to cover his mustache area. Surveyors also found food items in the walk-in freezer and walk-in refrigerator that were not labeled and did not have use-by dates. In the walk-in freezer, items that resembled scones, cookie doughs, apple scones, cinnamon rolls, and white chocolate scones were stored in clear plastic bags with no labels and no use-by dates. In the walk-in refrigerator, what resembled whipped topping was also stored in a clear plastic bag with no use-by date. The EC stated that kitchen staff were responsible for labeling and dating food items, and that staff had been in a hurry and forgot to do so. The EC also stated that the garbage can should have been covered when not in use and that the DC had removed his hair restraint and forgotten to put it back on. During interviews, the DC stated he was responsible for labeling and dating food items along with other kitchen staff, and that he had forgotten to do so. He also stated he had just gotten out of the bathroom and had forgotten to use the hair restraint. The RD, DM, and ADM each stated that kitchen staff were responsible for labeling and dating food items, that the garbage can should have been covered when not in use, and that all kitchen staff should have worn hair restraints while prepping. The facility policies reviewed stated that refrigerated and frozen foods are to be covered, labeled, and dated, that garbage cans should have lids replaced, and that food employees in preparation areas should wear hair restraints and beard restraints.
Food Storage, Labeling, and Hand Hygiene Failures
Penalty
Summary
The facility failed to store, prepare, and maintain food and food-contact sanitation in accordance with food safety standards. During observations in the main kitchen, two sanitizer buckets were found with sanitizer concentrations that tested at 0 ppm and 100 ppm, which did not match the manufacturer-recommended range posted in the kitchen areas. Follow-up testing later showed one set of buckets at 100 ppm, another at 350 ppm, and then again at 0 ppm on a later observation. Facility leadership gave differing explanations about which sanitizer dispenser should have been used and whether the buckets needed to be tested before use. The facility also had multiple food items in the main kitchen walk-in refrigerator, freezer, dry storage area, nourishment cooler, and unit kitchens that were unlabeled, missing use-by dates, missing open dates, or expired. Observations included prepared foods such as pancakes, French toast, pureed meats, vegetables, cheeses, eggs, desserts, breads, sauces, and individual serving cups that were stored without required date markings or with dates that had already passed. Several items in manufacturer packaging were also found without open dates or use-by dates, and some expired items remained in storage, including cereal, bread mix puree, dessert sauces, butter pats, and therapeutic nutrition supplements. During food preparation, a cook handling raw chicken thighs with gloves stopped to touch a speaker while still wearing the same gloves, then returned to handling the raw chicken without removing the gloves or performing hand hygiene. The DCNS stated the cook should have removed the gloves, washed hands, and put on clean gloves before returning to food preparation. The report also notes that the facility’s policy required handwashing before preparing food, after contamination, when returning to a workstation, and when switching between raw and ready-to-eat foods.
Improper Hair Restraints During Food Preparation and Service
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. During an observation on 06/10/2026 at 12:00 p.m., DA was assisting with serving the noon meal while wearing a black beanie that covered the top of his head but left his hair braids uncovered. During an observation on 06/11/2026 at 10:45 a.m., DM was preparing the noon meal while wearing a black headband with her hair uncovered. During interviews, DA stated the purpose of a hair net was to keep hair from getting into food and said he did not need to cover his braids, only his beard and top of head. He stated he had been trained in hair restraints while in the kitchen. DM stated all kitchen staff were to wear hair restraints covering all hair, including braids, and said she was aware DA was not properly wearing his hair restraint and had done an in-service with him on proper hair restraints on 06/10/2026. She also stated she wore a hair net over her head band but forgot to put it on. The ADM stated he was not aware kitchen staff were not properly wearing hair restraints and said all staff had been in-serviced on proper hair restraints while in the kitchen. Record review showed the facility policy required all employees in food preparation or utensil washing areas to wear a hairnet or hair covering.
Unsafe Food Storage in Kitchen and Nourishment Room Freezer
Penalty
Summary
Food was not stored in a safe manner in the main kitchen and in 1 of 2 nourishment rooms. During the initial tour of the main facility kitchen, there was no thermometer in the walk-in freezer, and the Kitchen Manager acknowledged that a stand-alone thermometer was not present. In the 300 Hall nourishment room freezer, the thermometer registered 30 degrees Fahrenheit, and there were 7 thawed ice cream bars stored inside. The Kitchen Manager confirmed the freezer temperature and agreed the ice cream bars were thawed. The facility policy titled Food & Beverage Standards of Excellence stated that food will be purchased, stored, prepared, and served in a sanitary manner and that proper food temperature is required.
Food Storage, Labeling, and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food items were properly labeled, dated, stored, and kept clean in the main kitchen and a 3rd floor kitchenette. During observation of the main kitchen, a walk-in storage freezer had boxes stored on the floor and frozen tater tots scattered across one corner of the freezer floor. A refrigerator used for some independent living residents contained a tray of tartar sauce portion cups that were undated, and the bottom shelf was dirty with crumbs and food debris. A walk-in freezer had sticky floors and frozen sausage links scattered on the floor. In the main kitchen refrigerator, a tray of red sauce portion cups was not labeled or dated, a Ziplock bag of sliced meat had a date of 5/6 and appeared to have a grayish white tint, and another Ziplock bag of seasoned meat was in a container with no label or date. A ceiling vent above the main stove had brown/black dust and dirt on it. The Dietary Director verified the undated and unlabeled food items, the food spilled on the freezer floors, the dirty vent, and the lack of a beard net on a cook with a short trimmed beard. In the 3rd floor kitchenette, the small refrigerator by the steam table contained 2 half gallons of skim milk, including one unopened container with a best by date of 6/7/26 and one opened container with approximately 1/2 cup left with a best by date of 6/6/26. A cook with a medium length beard was working on the serving side of the kitchenette and was not wearing a beard net. Nursing staff stated the milk should be tossed, and the cook stated the morning cooks should have reviewed the refrigerator items and that items past their dates should be thrown out. The Dietary Director and administrator stated staff were expected to ensure food items were dated and labeled when stored, refrigerators were reviewed for out-of-date items, beard nets were worn in the kitchen and serving areas, and refrigerators, freezers, and ceiling vents were clean.
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