Improper Hand Hygiene During Beverage Service
Summary
The facility failed to ensure food was distributed and served in accordance with professional standards for food service safety during a recertification survey. The Assistant Director of Nursing was observed serving beverages to multiple residents in the main dining room without performing proper hand hygiene. The staff member wore disposable gloves while serving but did not change them between serving different residents. Additionally, the Assistant Director of Nursing touched various surfaces, such as the beverage cart handle and a resident's walker, without changing gloves or sanitizing hands, and continued to serve beverages to residents. The Assistant Director of Nursing also touched their own face with bare hands while taking a beverage order and proceeded to serve a resident without washing or sanitizing hands. The staff member admitted to wearing gloves to prevent contamination of the ice but acknowledged that gloves were not necessary and that hand hygiene should have been performed. The surveyor confirmed that the sink was out of soap, which contributed to the lack of proper hand hygiene during the beverage service.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 Resident # 93 had no ill effects from the deficient practice noted during the meal service on 3/5/25. The resident was monitored for 5 consecutive days for any emotional distress with no issues noted. The resident’s care plan was reviewed and is in concert with the resident’s current needs and a medical record review completed with no abnormal findings. ADON was educated on proper hand hygiene while serving in the main dining room. She has since been re-audited and successfully redemonstrated understanding. All facility residents have the potential to be affected by the alleged practices. A meal service audit was conducted on all units to verify that disposable gloves were not being used during meal pass and that hand hygiene was performed properly. No further issues were identified. All nursing staff will be in-serviced regarding proper hand hygiene in accordance with professional standards for food service safety while serving meals. Weekly audits will be completed across all 3 meals in each dining room on a rotating basis by DON/designee to assure proper hand hygiene during meal service. Audits will continue until 100% compliance is attained for 4 consecutive weeks. The DON/ADON will review audits for compliance. Any negative findings will result in immediate education. The audit results will be reported at the monthly QAPI meeting. The frequency of ongoing audits will be determined by the QAPI committee based on audit results. The person responsible for the corrective action is the Director of Nursing/designee. Date of Compliance is 4/18/25.
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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