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
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The facility failed to keep the kitchen hood clean, removed moldy cantaloupe from storage only after it was observed, allowed a staff drink to be stored in the kitchen freezer, and observed an employee washing hands for only four seconds with visible substance still on the arm before serving food. Food and refrigerator temperature logs were incomplete, and the activities refrigerator was found with condensation, black buildup, and temperatures above the safe range while the AD reported freezer temperatures were not being checked.
Unsanitary food handling and storage conditions were observed in the main kitchen. Food was stored under pipes with ice buildup dripping onto items, several meat packages were left unsealed, cereal drawers were open, a foam cleanser sat on a prep table with food, rotten bananas were present, melted butter was left uncovered, a bag of buns touched the floor, and the Dietary Supervisor entered without a hair restraint or beard guard.
Food items in the walk-in cooler were found with expired use-by dates, missing labels or dates, and signs of spoilage, including discolored lettuce and opened cheese products left improperly stored. Surveyors also observed pink and brown substances on the kitchen ice machine baffle above the ice trough. The Head [NAME] acknowledged the storage issues and that the ice machine needed cleaning, while the DDM and Administrator stated that food labeling, dating, spoilage checks, and ice machine sanitation were expected.
Dishwasher temperatures in the main kitchen were not monitored to required levels. The log showed repeated wash and final rinse temps below the required range, and during observation the dish machine again ran below spec, with the wash cycle reaching 143 degrees and then 141 degrees and the rinse cycle reaching 177 degrees before not registering. The dining supervisor and food service unit supervisor both stated staff had not notified them about the low temps, despite staff saying they were supposed to record the readings and report out-of-range temps.
Dishwasher Rinse Cycle Failed to Reach Required Sanitizing Temperature: The facility failed to ensure 1 of 1 dishwasher reached the required high-temp rinse range. During observation, the wash cycle reached 153°F and the final rinse reached 150°F, below the posted 180-195°F requirement. The CD confirmed the machine should reach 180°F, and the temp log showed multiple rinse cycles below 180°F with no indication of correction.
Kitchen Sanitation and Food Labeling Failures: Surveyors observed a fryer, toaster oven, wall behind the dishwashing station, and hot holding trays/cookie sheets with heavy grease and grime buildup. Multiple canned goods, pantry snacks, prepared gravy, and prepared pureed chicken were also found without required use-by or expiration dates. Dietary staff and ADM stated staff were responsible for cleaning, labeling, and dating food items, but several items were left undated and the dietary mgr was unavailable.
Kitchen sanitation, food safety, and temperature monitoring failures
Penalty
Summary
The facility failed to keep the kitchen cooking hood clean. On 7/10/26 at 9:43 AM, the gray kitchen cooking hood vent was observed with a layer of brown particles on the outside of the hood vent. When asked about the kitchen cleaning schedule, the CM stated kitchen staff were to clean vents once per week, and when asked about the cooking hood vent, the CM stated she did not think the kitchen staff realized that it was also considered a vent. The facility failed to ensure food items were free from mold. On 7/10/26 at 9:16 AM, a box labeled cantaloupe was observed on a lower wire rack shelf in the dry storage area. Three cantaloupes were in the box, and one had a large oblong white fuzzy substance on it that was in contact with the other two cantaloupes. When asked about fruit ordering and inspection, the CM stated fruit was received every two weeks and inspected when staff went to use it. The CM identified the cantaloupe as bad, stated it had been ordered on 6/25/26, and removed the box from storage. The CM also stated the cantaloupe was white and moldy and should have been pulled on 6/30/26. The facility failed to prevent contamination risks related to staff practices and food safety monitoring. On 7/7/26 at 8:22 AM, a McDonald's cup containing a dark liquid was observed in the kitchen freezer, and [NAME] #1 stated the cup was theirs. The CM later stated personal drinks should not be kept in the freezer. On 7/9/26, [NAME] #2 was observed washing his hands for four seconds during tray line preparation at multiple times, and later had a cream, off-white substance stuck to the back of his right arm that was not washed off before serving food. The CM stated employees should be vigorously washing their hands for 20 seconds. The facility also failed to record required food and refrigerator temperatures. Food Temperature Logs for May 2026 through July 2026 showed missing food temperatures for multiple meals, including 5/17/26 dinner, 5/22/26 lunch, 5/23/26 breakfast, lunch, and dinner, 5/26/26 dinner, and 6/15/26 dinner. The CM stated puree food temperatures were recorded under minced and moist and that she did not catch that temperatures were not being done. The activities refrigerator temperature log for June 2026 was missing temperatures for 6/27/26 through 6/30/26, and the log had freezer sections crossed out even though ice cream bars were stored in the freezer. The AD stated he only checked refrigerator temperatures, did not check freezer temperatures, was the only staff member checking temperatures on weekdays, and temperatures were not checked on Saturdays and Sundays. On 7/9/26, the activities refrigerator was observed with condensation, black buildup on the lower shelf, and a thermometer reading above the safe line at 51 degrees; the AD later confirmed the refrigerator was at 42 degrees and stated it would not be appropriate to use anything in the refrigerator.
Unsanitary Kitchen Food Storage and Handling
Penalty
Summary
The facility failed to maintain sanitary conditions in the main kitchen to prevent potential cross-contamination or foodborne illness. During an observation of the kitchen, the deep freezer was found with food stored under pipes and fans with ice buildup attached to boxes of food items and dripping into food items underneath. A ham loaf and two other meat packages were not sealed and were exposed. In the dry storage area, drawers of cereals were unsealed and could allow for rodents. A can of foam cleanser was placed on a food prep table with food items, and a nearby table had multiple rotten or black bananas. The toaster area had a pan of melted butter left uncovered, and a cart had a bag of buns on the bottom touching the floor. The Dietary Supervisor entered the kitchen without a hair restraint or beard guard and confirmed the facility failed to maintain sanitary conditions in the main kitchen.
Food Storage and Ice Machine Sanitation Deficiencies
Penalty
Summary
Food was found stored in the walk-in cooler with multiple labeling and dating problems and several items showing signs of spoilage. During an observation with the Head [NAME], surveyors found containers of tuna, tomato soup, alfredo, brown gravy, cheezy rice, and egg salad with use-by dates that had passed, a metal steam pan with no label or date that appeared to contain grated cheese over pasta with a white creamy sauce, chicken noodle soup with no date, opened mozzarella cheese with no date, and an opened package of sliced American cheese left open to the air with no opened-on or use-by date. Two sealed bags of lettuce were also observed with brown discoloration and brown liquid in the bottom of the bags. Surveyors also observed the kitchen ice machine with pink and brown substances scattered across the entire baffle directly above the full trough of ice. During the observation, the Head [NAME] stated he understood that items were not stored correctly and that the ice machine needed to be cleaned. The District Dietary Manager stated that it was the Head Cook's or Food Service Manager's responsibility to ensure food was labeled and dated, that stored food should be checked daily for proper labeling and signs of spoilage, and that the ice machine should be wiped down daily with a monthly deep clean by maintenance. The Administrator stated that all food was expected to be labeled, dated, and stored correctly, spoiled items discarded immediately, and the ice machine maintained and sanitized properly.
Dishwasher Temperatures Not Monitored
Penalty
Summary
The facility failed to monitor dishwasher temperatures in the main kitchen. The dishwasher temperature log for July 2026 showed that the required wash cycle temperature was 160 degrees Fahrenheit and the final rinse cycle temperature was 180 degrees Fahrenheit, with instructions to report low temperatures to the supervisor immediately. The log documented multiple temperatures below the required range, including wash cycle temperatures of 154, 157, 150, 158, 159, and 150 degrees, and final rinse cycle temperatures of 173, 179, 174, and 174 degrees on several dates. During observation on 7/9/26 at 10:57 a.m., the dish machine was run with the wash temperature reaching 143 degrees and the final rinse reaching 177 degrees. When run again, the wash temperature reached 141 degrees and the rinse temperature did not register. The dining supervisor stated staff had not notified him about low dishwasher temperatures, and the food service unit supervisor verified the temperatures on the log did not reach the appropriate level and also stated staff had not notified her. Food service workers stated they monitored the wash and rinse temperatures and recorded them on the log, and the administrator stated the temperatures should be checked daily and reported if out of range. The facility policy dated 11/9/24 required dish machine temperatures to be monitored and recorded three times daily and low temperatures to be reported immediately.
Dishwasher Rinse Cycle Failed to Reach Required Sanitizing Temperature
Penalty
Summary
The facility failed to ensure minimum dishwasher temperatures were attained during the rinse cycle for 1 of 1 dishwasher. During observation, the dishwasher wash cycle reached 153 degrees Fahrenheit and the final rinse cycle reached 150 degrees Fahrenheit, while the manufacturer sign posted next to the machine instructed that the final rinse cycle range should be 180-195 degrees Fahrenheit. The culinary director confirmed the dishwasher was a high temperature machine and stated the final rinse cycle must reach 180 degrees Fahrenheit, and also confirmed the low temperature and that the dishwasher company needed to be called for service. Dishmachine Temperature Log for 7/2026 showed rinse temperatures logged at less than 180 degrees Fahrenheit for lunch use on 7/3/26 and for dinner use on 7/2/26, 7/3/26, and 7/7/26, with no indications of temperature correction. The infection preventionist stated the dishwasher temperature was expected to be hot enough to prevent the spread of infectious materials, and the administrator stated the dishwasher was expected to sanitize dishes and that staff should stop using it and report it if it was not reaching the correct temperature. The sanitation policy revised 1/10/25 instructed that the dishwasher rinse temperature specification was 180 degrees Fahrenheit and that if temperatures were not reached, culinary staff were to stop using the machine immediately, contact their supervisor, and begin manually washing dishes.
Kitchen Sanitation and Food Labeling Failures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During observations of the kitchen, surveyors found the fryer soiled with a thick coating of grease and grime on both sides of the outside of the fryer, the toaster oven soiled with a thick layer of grime and grease throughout the machine, the wall behind the dishwashing station covered with a yellow layer of grease and grime and hardwater stains, and hot holding trays/cookie sheets coated with a thick layer of black and brown grease build-up across the entirety of the pans. Surveyors also observed multiple food items without required dates. Three cans of tomato soup, three cans of chicken noodle soup, and two cans of cream of mushroom soup were observed without use-by dates. A container of prepared gravy was observed without an expiration or use-by date, and 10 individual containers of prepared pureed chicken were observed in the refrigerator without an expiration or use-by date. On a later observation, the same undated canned soups were still present, and additional dry pantry items, including a box of fig bars and a box of individual Ritz crackers, were also observed without use-by dates. Interviews with dietary staff and administration showed that staff were responsible for cleaning the kitchen, labeling and dating food items, and putting away inventory, but several staff were unaware of the undated items or the extent of the buildup on equipment and surfaces. Staff stated the dietary manager usually double-checked labeling and dating, but the dietary manager was on leave and unavailable. The facility policy required kitchens and food storage areas to be kept clean and sanitary, equipment to be free of grime, and all dry, refrigerated, and frozen foods to be labeled and dated.
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