Deficient Food Storage, Sanitation, and Equipment Maintenance in Kitchen
Penalty
Summary
The facility failed to maintain food storage, preparation, and kitchen equipment in accordance with professional standards for food service safety. During a kitchen tour, an open bag of grits was found unsealed and undated in dry storage, contrary to facility policy requiring opened dry food items to be tightly closed, labeled, and dated. The Registered Dietitian (RD) confirmed the lack of proper sealing and dating, acknowledging the risk of contamination. Additionally, several kitchen environment issues were observed, including a worn and damaged walk-in refrigerator floor, walls and ceilings with missing paint, texture, and signs of water damage, and a fruit and vegetable sink lacking an air gap for backflow prevention. The Maintenance Supervisor stated that maintenance needs should be logged by kitchen staff, but no requests for repairs had been made according to the facility's work history report. Further deficiencies included improper storage of kitchenware, with five metal bowls and nine steam table pans stacked and stored while still wet, which the RD confirmed was not compliant with air-drying requirements. Damaged small wares were not discarded as required by policy; a fry pan with extensive markings and scratches, a discolored and deeply scored cutting board, beverage pitcher lids with cracks and chips, and a can opener with missing metal were all found in use or storage. The RD and facility policies confirmed these items should have been discarded or replaced due to their condition, which could harbor bacteria or introduce foreign objects into food. Additionally, a large mixer was found with hardened, crusted build-up and rust-colored debris behind the mixing bowl, indicating inadequate cleaning. The RD confirmed the mixer was dirty and needed cleaning. These findings, based on direct observation, interviews, and record review, demonstrated a failure to adhere to both facility policies and FDA Food Code requirements for food safety, sanitation, and equipment maintenance. The deficiencies had the potential to cause foodborne illness for the 91 residents consuming facility-prepared meals.
Plan Of Correction
04/07/2025. b) The rough textured scratch was repaired by Maintenance Supervisor on 05/07/2025. c) The walk-in refrigerator floor was repaired by Maintenance Supervisor on 05/07/2025. d) The fruit and vegetable cleaning sink was repaired by Maintenance Supervisor on 05/07/2025. e) The ceiling cracks above the food service area were repaired by Maintenance Supervisor on 04/11/2025. f) The fruit and vegetable cleaning sink was repaired to have an airgap by Maintenance Supervisor on 05/07/2025. g) The wet metal bowls and steam table pans were removed, washed and left to air dry on 04/07/2025. h) The discolored fry pan and cutting board were removed and thrown away on 04/07/2025. i) The can opener was removed and thrown away on 04/07/2025. j) The discolored and cracked beverage lids pan and cutting board were removed and thrown away on 04/07/2025. k) The large mixer was removed and cleaned on 04/07/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: I) All residents have the potential to be affected by this deficient practice. No other areas were identified as having this same deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: m) In-Service was provided by the Registered Dietician to the dietary staff on 04/11/2025 through 04/15/2025 regarding the importance of labeling and dating food items, ensuring that staff are monitoring properly air drying items before placing them for storage. In-Service was provided by the Administrator to the Maintenance Department staff on 05/07/2025 regarding the importance of making rounds in all of the necessary areas in the kitchen and that there is no buildup on equipment that items needing repair are reported immediately in an effort to avoid foods becoming affected. n) Dietary Manager and/or designee to conduct random audits of the kitchen to look for food that may be unlabeled or undated and checks that equipment is stored properly, clean and not discolored along with items requiring to be reported for repair/replacement. Any issues identified will be reviewed, validated and immediately corrected. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system. o) Dietary Manager and/or designee to conduct random audits of the kitchen to look for food that may be unlabeled or undated and checks that equipment is stored properly, clean and not discolored along with items requiring to be reported for repair/replacement. Any issues identified will be reviewed, validated and immediately corrected. Dietary Manager and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations until negative trends resolve. F 812 F880 Infection Prevention & Control How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: