Deficiencies in Food Service Safety and Cleanliness
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, or served following professional standards for food service safety in both the main kitchen and resident unit nutrition areas. During the initial inspection, surveyors observed a build-up of debris on the manual can opener and mixer, dust and dirt on fire extinguishers, and a large pool of free-standing water on the floor of the walk-in refrigerator. Additionally, the storage area for clean pots, pans, and food containers had items that were not fully dried, and the rolling toaster had a significant amount of debris underneath. The final rinse pressure on the dishwasher was below the recommended level due to a malfunctioning gauge. In the East nutrition area, temperature logs for the refrigerator and freezer were missing for several dates, and there was a noticeable accumulation of dirt, grime, and food particles on various surfaces, including the refrigerator/freezer unit, microwave, and drawers. Interviews with the Director of Food Services and the Environmental Services Director revealed that staff were not diligent in cleaning and maintaining the equipment and kitchen areas. The Environmental Services Director acknowledged the lack of cleanliness and mentioned the development of a duty list to ensure daily responsibilities are completed.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 Corrective Action for those identified: Manual can opener was found to have build-up of debris in the cutting area of the device. Mixer had dirt and debris on and under the device. Dust and dirt were on top of two fire extinguishers in the main kitchen. All three of these items were addressed immediately and cleaned during/after the initial walk through. Staff were reminded during a daily kitchen huddle on (MONTH) 6th that the areas need to be cleaned daily. East Nutrition Area: Temperature logs for the refrigerator/freezer in the East Nutrition area were missing dates from (MONTH) 6, 8, 9, 10, and 12, 2025. Dirt and grime was found on top of refrigerator/freezer unit. Dirt, grime, and food particles were found on the freezer bottom and shelves. Dirt, grime, and food particles were found on the refrigerator bottom and shelves. There was dirt and grime on the seals of the refrigerator and freezer. There was dirt, grime, and food particles within the microwave. There was dirt, grime, and food particles built up on the drawers under the microwave. The above listed items were addressed with the staff members responsible for the area at a daily staff huddle on (MONTH) 6th, 2025. Staff were reminded that they are responsible for the cleaning of the refrigerator/freezer, as well as the microwave and drawers underneath. Staff were also reminded that the refrigerator/freezer temps need to be taken and recorded daily. The refrigerator/freezer unit, microwave, and drawers under the microwave were properly cleaned on Friday (MONTH) 28th. West Nutrition Area: Temperature logs for the refrigerator and freezer were found to be missing dates for (MONTH) 9, 10, and 12, 2025. Dirt and grime was found on top of refrigerator/freezer unit. Dirt, grime, and food particles were found on the freezer bottom and shelves. Dirt, grime, and food particles were found on the refrigerator bottom and shelves. There was dirt and grime on the seals of the refrigerator and freezer. There was dirt, grime, and food particles within the microwave. There was dirt, grime, and food particles built up on the drawers under the microwave. The above listed items were addressed with the staff members responsible for the area at a daily staff huddle on (MONTH) 6th, 2025. Staff were reminded that they are responsible for the cleaning of the refrigerator/freezer, as well as the microwave and drawers underneath. Staff were also reminded that the refrigerator/freezer temps need to be taken and recorded daily. The refrigerator/freezer unit, microwave, and drawers under the microwave were properly cleaned on Friday (MONTH) 28th. Walk-in freezer was found to have a large puddle of free-standing water on the floor. Eastern Refrigeration was called to come address the puddle. A small water leak was found around the walk-in cooler and fixed. The storage area for clean pots, pans, and food containers had multiple containers stacked together that were not fully dried. Containers, pots, and trays were put away wet and contained moisture. Shortly after inspection, all pots and pans were pulled and inspected to ensure there was no wet nesting. The staff members responsible for cleaning and putting away dishes were reminded that all pots, pans, and containers need to be fully dried and contain no moisture before they are put away. The rolling toaster contained a large amount of debris under and behind the apparatus. The rolling toaster was moved and the counter was thoroughly cleaned. The issue was addressed with staff at a daily kitchen staff huddle on (MONTH) 6th, 2025. Responsible staff were reminded that this area needs to be cleaned after each use. Dirt and grime were found on the shelving unit above the grill cooking area. The shelving unit was wiped down and properly cleaned shortly after inspection. Discussion with the cooks took place on (MONTH) 6th, 2025 at daily staff huddle reminding the responsible staff members that the kitchen shelving unit needs to be cleaned each day. Final rinse pressure on the dishwasher was 13psi. The signage on the device had a recommendation of 20psi (+ or - 5psi). At the time of inspection, management was aware that the psi was not correct and a call had been made to Action Service, our repair company. (NAME), the Tech from Action Service, had come out and determined the machine was functioning as it should but there was a problem with the PSI Gauge and sensor. The part was immediately ordered and replaced/fixed on Tuesday (MONTH) 4th. Identification of other residents and corrective action: All above listed items will be audited at a frequency of twice per week. The Nutrition Management team already conducts a monthly food safety/sanitation audit. The audit frequency will change from monthly to twice per week for a period of 3 months or 90 days. Measures and Systemic Changes: Education and In-Servicing will take place with Nutritional Services staff to ensure compliance. Twice a week audits will be tracked and reviewed at monthly QAPI meetings measuring compliance of deficient items. Monitoring: Twice a week audits will be tracked and reviewed at monthly QAPI meetings measuring compliance of deficient items. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation, or continuation of audits will be based on QAPI Committee recommendations. Responsible person/title and date of correction: Joe Clemens, Manager of Nutrition Services, by 3/31/25.