Food Safety Deficiencies in Kitchen Operations
Summary
The facility failed to adhere to professional standards for food service safety during one of three visits to the main kitchen. Observations revealed that the walk-in refrigerator on the dairy side had an internal temperature of 49 degrees Fahrenheit, exceeding the acceptable range of 35 to 40 degrees Fahrenheit. Several food items, including an egg platter, a tuna platter, and nutritional juice drinks, were found with internal temperatures above the required 40 degrees Fahrenheit. Additionally, a large container of raw chicken and raw meat in the walk-in meat refrigerator were improperly stored, with one container showing a pool of liquid at the bottom. Further issues were noted in the dry storage room, where dented cans of sliced pineapples and tomato sauce were not segregated with a 'do not use' sign. An opened bottle of extra light amber honey was found without a known opening date. A personal Styrofoam cup of coffee was observed in the food production area, and a large metal container was coated with a dried unidentified substance. The facility's use of sanitation solution was also problematic, as a red bucket tested with Hydrion strips showed an excessive level of 400 parts per million, which the Dietary Manager acknowledged as too much solution.
Plan Of Correction
F812 FOOD PROCUREMENT, STORE/PREPARE/SERVE-SANITARY What corrective action(s) will be accomplished for those residents found to have been affected by the practice: In the allegation of the Walk-in refrigerator on the dairy side was 49° not the necessary 40°. Dietary staff will be in-serviced to check walk-in refrigerator temperatures and ensure it is 40° or below. If not, to inform maintenance to fix/adjust the temperature. In the allegation of the Egg platter from dairy walk-in was 43.7° not the necessary 40°. Dietary staff will be in-serviced not to use refrigerated food with a temperature above 40°. In the allegation of the Scoop of Tuna from the dairy walk-in was 44° not the necessary 40°. Dietary staff will be in-serviced not to use refrigerated food with a temperature above 40°. In the allegation of the Container of nutritional juice drink from the dairy walk-in was 46° not the necessary 40°. Dietary staff will be in-serviced not to use refrigerated food with a temperature above 40°. In the allegation of Another Container of nutritional juice drink from the dairy walk-in was 47.1° not the necessary 40°. Dietary staff will be in-serviced not to use refrigerated food with a temperature above 40°. In the allegation of Raw chicken exposed and dated, Dietary staff will be in-serviced to properly seal and date open items and how long before they need to be disposed of. In the allegation of Raw meat dated, pool of on the bottom of the meat container. Dietary staff will be in-serviced as to the proper storage of raw meat. In the allegation of Bag of unidentified meat dated, Dietary staff will be in-serviced to properly label, date, and store refrigerated items. In the allegation of Red bucket having a reading of 400 parts per million indicating too much sanitation solution in the bucket. Dietary staff will be in-serviced on proper measurements for sanitation solution. In the allegation of Dry storage had a dented can of sliced pineapples that was not placed by the sign "do not use". Dietary staff will be in-serviced where to place and not use dented cans. In the allegation of Dry storage had 2 dented cans of tomato sauce that was not placed by the sign "do not use". Dietary staff will be in-serviced where to place and not use dented cans. In the allegation of Dry storage Open bottle of extra light amber honey was half used and was not dated as to when it was opened. Dietary staff will be in-serviced on proper labeling and storage of open items in the dry storage. In the allegation of Food prep area had a person 20 oz Styrofoam cup of coffee present. Dietary staff will be in-serviced not to have eat or drink or leave personal food in the kitchen. In the allegation of a Large metal container with a dried unidentified substance coating the surface. Dietary Staff will be in-serviced on proper cleaning of metal containers. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: Dietary staff will be in-serviced to check walk-in refrigerator temperatures and ensure it is 40° or below. If not, to inform maintenance to fix/adjust the temperature. Dietary staff will be in-serviced not to use refrigerated food with a temperature above 40°. Dietary staff will be in-serviced to properly seal and date open items and how long before they need to be disposed of. Dietary staff will be in-serviced as to the proper storage of raw meat. Dietary staff will be in-serviced to properly label, date, and store refrigerated items. Dietary staff will be in-serviced on proper measurements for sanitation solution. Dietary staff will be in-serviced where to place and not use dented cans. Dietary staff will be in-serviced on proper labeling and storage of open items in the dry storage. Dietary staff will be in-serviced not to eat or drink or leave personal food in the kitchen. Dietary Staff will be in-serviced on proper cleaning of metal containers. Random QA audits will be conducted by the Dietary Manager or a qualified Designee, weekly for one month, then biweekly for another one month, and then monthly for one month or until substantial compliance has been determined. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audits will be conducted by the Dietary Manager or a qualified Designee, weekly for one month, then biweekly for another one month, and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met.
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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