Sanitation and Expired Food Issues in Kitchen
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as observed during a survey. Several issues were noted, including peeling paint and rust-like surfaces on tables in the food preparation area, pitchers with leftover sticker debris, and a plastic serving cart with scratches and stains. The floor around cooking appliances was soiled with debris and a black liquid-like substance, and the plate warmer had visible dried brown substance or corrosion. Additionally, the dispensing hose and nozzle for the juice bin were found lying directly on the floor, and a plastic bin with syrup containers was sticky. The oven handle was greasy with dried debris and carbon build-up, and the walk-in refrigerator had brownish-black debris around the frame. Clean utensils were stored in a dirty plastic bin on a utility cart with dirty items, and water was pooling on the floor near the ovens and steamer. The facility also failed to ensure that food items were not past their use-by or expired dates. In the dry storage area, several expired items were identified, including large cans of chicken and dumplings, chili, a case of jelly, a can of beef stew, a can of chili con carne, a jar of peanut butter, and cases of butterscotch pudding, pinto beans, carrots, and peanut butter. Additionally, four packages of walnuts had unreadable hand-written dates and lacked use-by dates. The Certified Dietary Manager was unable to provide use-by dates by the lot number for these items. These deficiencies could potentially affect 72 of the 75 residents who consume an oral diet at the facility.
Plan Of Correction
F812 Food Procurement, Store/Prepare/Serve- Sanitary 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. Table in food preparation area with peeling paint on and shelf has been sanded and painted on. B. Table in food preparation area with rust-like surfaces have been sanded and painted on. C. Dissolvable stickers are being used for dating the pitchers and thoroughly cleaned when removed. D. Plastic serving cart with scratches and staining has been discarded. E. Staff have been educated to thoroughly clean floor at the end of each meal. F. Plate warmer has been thoroughly cleaned, sanitized, and added to the weekly cleaning schedule. G. The juice machine has been replaced, and the hoses are secured. H. Condiment bins are being cleaned and sanitized after each use prior to restocking. I. Oven is being wiped down after each use and thoroughly cleaned weekly. J. Refrigerator gaskets are being wiped down daily. K. Separate areas designated for clean and dirty items to avoid cross-contamination. L. Water pooled along the wall was cleaned on the spot. Steamer has been serviced with new gasket in place to prevent leaks. M. Chicken and dumplings discarded 2/10/2025. N. Canned chili discarded 2/10/2025. O. Case of jelly discarded 2/10/2025. P. Case of beef stew discarded 2/10/2025. Q. Can of chili con carne discarded 2/10/2025. R. Jar of Skippy peanut butter discarded 2/10/2025. S. Case of butterscotch pudding, case of pinto beans, case of carrots, and case of peanut butter all labeled with "Use by" dates. T. Four packages of walnuts discarded on 2/10/2025. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; CDM completed a sanitation audit of the kitchen on 2/17/2025 to include but not limited to the doors, door seals, floors, juice machine, dish racks, can opener, kitchenware, food storage, sanitation solution, and equipment function. No negative findings. CDM completed a food storage audit on 2/17/2025 to ensure all food items are dated, labeled and packaged properly to prevent contamination and growth of organisms. No negative findings. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; LNHA initiated ongoing education with CDM and dietary staff on the components of this regulation with emphasis of following proper sanitation, kitchen/nourishment room cleaning schedules, safe food handling to prevent the outbreak of foodborne illness, proper food storage including labeling and dating food items. LNKA initiated ongoing education with CDM and dietary staff on proper notification to the maintenance staff when issues or concerns are identified. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; CDM/Designee to conduct a sanitation audit of the kitchen 5 days weekly x 2 weeks, 2 days weekly x 2 weeks and then weekly x 2 months or until substantial compliance is met ensuring the kitchen is meeting the sanitation requirements as per federal guidelines. CDM/Designee to conduct a food storage audit 5 days weekly x 2 weeks, 2 days weekly x 2 weeks and then weekly x 2 months or until substantial compliance is met to ensure all food items are dated, labeled and packaged properly to prevent contamination and growth of organisms. The findings of these quality reviews are to be reported to the Quality Assurance/Performance Improvement Committee monthly x 3 months, or until the committee determines substantial compliance.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to use beard restraints during food prep and meal service was observed when two cooks with visible facial hair handled and checked food without beard coverings. One cook said he was unsure a beard restraint was required, and the other said staff never wore them. The KL stated beard restraints were required, but none were available on the hygiene supply shelf, which contained gloves, hair restraints, and aprons.
Food Storage and Personal Hygiene Deficiencies: A Cook was observed preparing food without required hair or beard covering, and multiple food items in the freezer, refrigerators, and kitchenette were found without open dates. Surveyors also found expired Greek yogurt in the walk-in refrigerator. The CDM stated items should be labeled with open dates and expired items discarded, while the facility policy required food service staff to wear a hair net or appropriate hair covering during food production and clean-up.
Improper Thawing of Frozen Chicken: Staff thawed frozen breaded chicken in a 3-compartment sink without cold running water instead of using an approved defrosting method. A Cook said she removed the chicken from the freezer about an hour earlier, and the DM confirmed the chicken was thawed in the sink after staff forgot to remove it from refrigeration earlier. The facility's policy required thawing in refrigeration, under running water, in a microwave under specific conditions, or as part of the conventional cooking process.
Unlabeled refrigerated food items were observed in the kitchen, including red gelatin, sausage patties, and two pitchers of tea. The DS confirmed the items were not labeled and stated the tea was not labeled before being served at lunch, while the ADM stated all food in the refrigerator should be labeled and dated per facility policy.
Dietary staff failed to store, prepare, and serve food in a sanitary manner. Observations showed lemonade left on top of an ice machine, oatmeal placed on a serving area, sausage links without a date or label, chicken stored above potatoes without a date, and a refrigerator without a thermometer. During meal service, staff touched the inside of bowls and handled grilled cheese sandwiches and other food items with gloved hands without changing gloves or performing hand hygiene.
Ice Machine and Water Filter Not Properly Cleaned: An observation found black and brown substance on the ice machine's water curtain guard and a dark brown water filter behind the machine. The dietary manager was unsure when the ice machine was last cleaned or how often the filter was changed, while the ADM believed it had been checked and cleaned within the prior week. The maintenance supervisor said he was responsible for cleaning and maintaining the machine, changed the filter monthly, visually inspected it weekly, and deep cleaned it in July, but may have missed part of the guard.
Failure to Use Beard Restraints During Food Preparation
Penalty
Summary
The facility failed to ensure the proper use of beard restraints during food preparation and meal service. During observation and interview, one cook was seen taking the temperatures of oatmeal and scrambled eggs while having gray whiskers covering his chin and lower cheeks, and he was not wearing a beard restraint. When asked about beard restraints, he stated he was not sure he was supposed to wear one and said no one in the kitchen wore beard coverings and he would not know where to find one if required. A second cook was observed stirring separate pots of vegetables and chicken to be used in soup while having black whiskers covering his chin and cheeks and not wearing a beard restraint. He stated kitchen staff never wore beard coverings and the facility had never required this, adding that they probably should be wearing them. The kitchen lead stated he thought beard restraints were required and identified a shelf for hygiene supplies, but the shelves contained disposable gloves, hair restraints, and aprons and did not contain beard restraints. He stated the facility did not appear to have any beard coverings and that he would include them on his next order. A policy dated 6/19/19 directed staff to wear hair coverings and keep mustaches, sideburns, and beards neatly trimmed.
Food Storage and Personal Hygiene Deficiencies
Penalty
Summary
The facility failed to meet professional standards for food storage and personal hygiene during observations of the kitchen and refrigeration areas. On 8/10/26 from 8:10 AM to 9:30 AM, Staff B, the Cook, was observed not wearing a hair or beard net while working. During the same observation, Freezer #1 contained multiple food items without open dates, including cheese ravioli, salmon patties, onion rings, sweet potato fries, wings, and chicken strips. The double-door refrigerator also contained numerous undated items, including several dressings and sauces, lettuce, lime juice, stuffed queen olives, banana pepper rings, soy sauce, teriyaki sauce, sweet and sour sauce, and red hot wing sauce. The walk-in refrigerator contained additional items without open dates, including strawberry yogurt, lettuce, almond frosting, pepperoni slices, ice cream, and tilapia. The walk-in refrigerator also contained five 32-ounce containers of Greek yogurt that had expired on 7/29/26. On 8/11/26 at 10:36 AM, Staff B was observed wearing a baseball cap and beard net while preparing food. Later that day at 11:25 AM, the refrigerator in the small kitchenette contained undated whole milk, fat-free milk, and 2% milk. Staff A, the Certified Dietary Manager, stated that items were expected to be labeled with an open date and expired items were to be discarded once expired, and she said she would need to review the facility policy regarding hair and beard nets because she believed short hair did not require a hairnet. The facility’s personal hygiene policy required food service staff involved in food production and clean-up to wear a hair net or appropriate hair covering, and the labeling and dating policy required all prepared, opened, stored, or repackaged food items to be properly labeled and dated, with improperly labeled, undated, expired, or unidentifiable items not served and discarded.
Improper Thawing of Frozen Chicken
Penalty
Summary
The facility failed to thaw frozen chicken using an approved method of defrosting. During an initial kitchen walkthrough, surveyors observed 3 bags of frozen breaded chicken leg drums sitting in a 3-compartment sink without cold running water. A later observation showed the same chicken bags placed in a basin inside the 3-compartment sink, again without cold water. Staff A, Cook, stated she had removed the chicken from the freezer about an hour earlier and was thawing it in the sink. The lunch menu for that day documented chicken drumsticks. The Dietary Manager acknowledged that Staff A thawed the frozen breaded chicken in the 3-compartment sink. The DM stated kitchen staff had forgotten to remove the chicken from the refrigerator earlier and reported that staff were expected to thaw chicken in the refrigerator or under cold running water. The DM also noted a small hole in the chicken bag and stated staff did not want the breaded chicken to get wet. The Administrator stated dietary staff were expected to thaw frozen chicken in the refrigerator or under cold running water. The facility's Food Preparation Policy required frozen meats and leftovers to be thawed only by approved methods, including refrigeration, running water, microwave under specific conditions, or as part of the conventional cooking process.
Unlabeled refrigerated food items
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 the initial kitchen tour on 08/11/2026 at 09:35 a.m., surveyors observed a bowl of red gelatin with no label, a bag of sausage patties with no label, and two pitchers of tea with no label in the refrigerator. During interviews, the DS confirmed that the gelatin and sausage patties were not labeled and stated she did not know the tea needed to be labeled before being served at lunch in about an hour and a half. She stated the gelatin, sausage patties, and tea were not labeled when placed in the refrigerator and that all items should be labeled when placed there. The ADM also stated that all food in the refrigerator should be labeled and dated, and the facility policy titled Storage of Frozen and Refrigerated Foods required cold or frozen foods in the refrigerator to be labeled with the date opened or prepared, time, and expiration or use-by date.
Unsafe Food Storage and Improper Food Handling
Penalty
Summary
The dietary department failed to store, prepare, and serve food in a sanitary manner during kitchen observations. During an initial tour, a pitcher of lemonade was observed sitting on top of the ice machine, a bowl of oatmeal was placed on top of the serving area for plates, and a clear bag of sausage links was sitting on a plastic cart without a date or label. Staff stated the sausage had been opened the day before and should have been dated and stored in the refrigerator when not in use. In the walk-in refrigerator, a plastic container covered with aluminum foil and labeled chicken had no date and was stored inside another pan with ice on the second shelf above potatoes. Staff stated the chicken would be used the next day and should have been stored on the bottom shelf and dated before being placed in the refrigerator. A refrigerator in [NAME] Hall did not have a thermometer, and staff confirmed none could be located. During meal service, staff were observed touching the inside of bowls while grabbing multiple bowls at a time, and another staff member touched grilled cheese sandwiches with a gloved hand while flipping them and then returned to food handling after touching a cooler and handling cheese without changing gloves or performing hand hygiene. The assistant dietary manager stated the lemonade should have been stored in the cooler, the sausage should have been labeled and dated, the chicken should have been dated and stored on the bottom rack, the refrigerator should have had a thermometer, and staff should have handled bowls by the outside and washed hands or changed gloves when handling food.
Ice Machine and Water Filter Not Properly Cleaned
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen reviewed. During an observation on 08/10/2026 at 9:30 AM, the ice machine in the dining area had a black and brown substance on the white plastic water curtain guard above the ice, and the water filter behind the machine was dark brown in color. The dietary manager stated she was responsible for the kitchen area but was not sure of the cleaning timeframe or when the ice machine was last cleaned, and she did not know how often the water filter was changed. The administrator stated the maintenance supervisor was responsible for maintaining the ice machine and water filter and believed it had been checked and cleaned in the last week, but she needed to ask for the cleaning schedule and filter change dates. The maintenance supervisor stated he had been responsible for the ice machine for over a year, changed the water filter monthly and as needed, visually inspected it weekly, and deep cleaned the ice machine in July 2026. He stated he may have missed the small section of the guard with the dark substance. The facility policy required cleaning and disinfecting ice machines and ice storage chests according to the manufacturer's instructions, and the Manitowoc service manual stated the ice machine should be cleaned and sanitized every six months, or more often if needed based on water quality.
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