Food Safety and Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain specific food items in accordance with professional standards for food safety and infection control prevention. During the initial tour of the kitchen, surveyors observed an opened and undated container of thickened milk in the refrigerator and an opened, undated bag of powdered sugar wrapped with plastic wrap in dry storage. The Food Service Director, when interviewed, stated they were unaware that these items were not dated after opening, which was contrary to the facility's policy requiring all unused portions and open packages to be covered, labeled, and dated using the Medvantage/Freshdate labeling system. Additionally, the facility did not ensure proper use of disposable gloves by dietary aides during meal service. Three dietary aides were observed failing to change gloves after touching non-meal service objects. Dietary Aide #26 was seen using gloves to handle an ink pen, clipboard, and garbage lid before continuing meal service without changing gloves. Dietary Aide #27 used gloves to touch a door handle and refrigerator door before preparing meal trays. Dietary Aide #28 answered a phone call while wearing gloves and then continued to serve meals without changing them. The Food Service Director confirmed that all dietary staff had been trained on the policy requiring glove changes between tasks, but the aides did not adhere to this policy during the observations.
Plan Of Correction
Plan of Correction: Approved March 21, 2025 F 812 Food Procurement I: Immediate Corrections - The opened undated container of thickened milk and undated bag of powdered sugar were all discarded on 2/20/25. - The Dining Service staff that were identified during observations were immediately provided with an in-service education on proper disposable glove usage on (MONTH) 14 through (MONTH) 16, 2025. II: The following corrective actions will be implemented to identify other residents who may be affected by the same practice: - All freezers, refrigerators, and dry storage areas were inspected for any additional items that may be unlabeled or past their expiration date and holding. - All Dining Service Staff were provided in-service education on (MONTH) 25, 2025, on proper food storage procedures including importance of labelling all opened items and monitoring food expiration dates, including all dates identified as “sell-by,” “best-by,” “enjoy-by,” or “use-by.” - All Dining Service Staff were provided in-service education on (MONTH) 14 – (MONTH) 16, 2025, on proper disposable glove usage. III: The following system changes will be implemented to ensure continuing compliance with regulations: - The Administrator and Director of Food Services reviewed the policy titled, Production, Purchasing, Storage: Food and Supply Storage. There were no revisions necessary. - The Administrator and Director of Food Services reviewed the policy titled, Sanitation and Infection Control: Disposable Glove Use Policy. There were no revisions necessary. - All Dining Services Staff were provided with in-service education on the facility’s policy titled Production, Purchasing, Storage: Food and Supply Storage by the Director of Food Services. - All Dining Services Staff were provided in-service education on the facility’s policy titled, Sanitation and Infection Control: Disposable Glove Use Policy by the Director of Food Services. IV: The facility’s corrective action will be monitored to ensure the deficient practice does not recur by utilizing the following quality assurance practices: - Director of Food Services will develop an audit tool entitled, “Labeling of Food Products.” This tool will be utilized by the Dining Service Managers and will conduct daily inspection of all refrigerators, freezers, and dry storage areas to ensure all items are properly labelled, dated, and within appropriate date ranges. The audit will be conducted weekly for 3 months. - Director of Food Services will develop an audit tool entitled, “Disposable Glove Use.” This audit tool will be utilized to monitor compliance of five (5) Dining Service Staff members on Sanitation and Infection Control with Disposable Glove Use. The audit will be conducted weekly for 3 months. - A quantitative summary of findings and corrective actions will be reported monthly to the Quality Assurance Performance Improvement committee by the Food Service Director. Responsible Person: The Dining Director is the person responsible for ensuring all the above actions are completed.