Deficiencies in Food Safety, Sanitation, and Labeling Practices
Penalty
Summary
Surveyors identified multiple failures in food safety and sanitation practices within the facility's kitchen and food storage areas. During an initial kitchen tour, several food items were found to be improperly labeled and dated, including containers of dry pasta and kimchi with incorrect or expired dates, and an opened bottle of oyster sauce with inconsistent labeling. The facility's policy required clear date marking and timely disposal of expired items, but these procedures were not followed. The Dietary Services Supervisor (DSS) acknowledged that some labels were incorrect and that the kimchi had not been prepared on the date indicated. Further observations revealed that kitchen utensils and equipment were not maintained in a sanitary condition. Two rubber spatulas had corroded edges, another had a melted handle with a brown coating, and a small pitcher had a melted bottom. Additionally, two cutting boards were heavily marred and chipped, making them difficult to clean and sanitize. The DSS confirmed these findings. The residents' refrigerator, used to store food brought in from outside, was found to have brown food residue on one of the shelves, and this was verified by a registered nurse. The facility also failed to post required handwashing signage at the kitchen handwashing station on multiple occasions, as required by the USDA Food Code. The DSS admitted that the signage was not posted as it should have been. In a resident's room, two pieces of bananas brought in by a visitor were found in a clear plastic bag without proper labeling or dating, contrary to facility policy. Staff members, including a CNA and an LVN, were unable to determine when the bananas had been brought in and confirmed that perishable foods should be dated. The resident involved had no capacity to make decisions and was on a specialized diet, as documented in their medical record.
Plan Of Correction
F812 Food Procurement, Store/Prepare/Serve-Sanitary Corrective action for residents found to have been affected by this deficiency: -The licensed nurse (LVN 2) discarded the unlabeled pieces of banana immediately found by Resident 22's bedside table. Corrective action for residents that may be affected by this deficiency: -Cook 1 discarded the expired container of dry pasta immediately on 6/16/25. The DS discarded the opened mislabeled bottle of oyster sauce and kimchi immediately on 6/16/25. -The multiple pieces of equipment found damaged were discarded immediately by the DS on 6/16/25, including the rubber spatulas, pitcher, and cutting boards. -DS ensured the resident refrigerator was cleaned immediately, with the brown food residue removed on 6/16/25. -DS posted proper handwashing signage immediately at the handwashing station on 6/17/25. -DS in-serviced dietary staff initiated on 6/16/25 and completed for all dietary staff on 6/17/25, utilizing P&Ps "Date Marking for Food Safety" and "Sanitation Inspection", emphasizing the importance of proper labeling and dating and cleaning of equipment. -The DON, Director of Staff Development (DSD) and DS conducted an in-service with all the dietary and nursing staff initiated on 6/16/25 and completed on 7/9/25, utilizing the P&P "Use and Storage of Food Brought in by Family or Visitors" on proper labeling and dating of outside food, and ensuring food is discarded if not properly labeled and that the resident refrigerator is cleaned following the cleaning schedule. Measures that will be put into place to ensure that this deficiency does not recur: -DS, RD, or trained designee will complete daily kitchen rounds, 5 times per week X 3 months, and the RD will complete their monthly sanitation audit, ensuring proper labeling & dating in all areas, including the resident refrigerator and bedside tables, and compliant equipment cleaning, discarding any damaged equipment. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: -DS or RD will report their findings regarding proper labeling & dating, cleaning of equipment and outside food for residents to the QA committee for discussion and further recommendations. The QA will continue monitoring for a minimum of 3 months or until substantial compliance is achieved. Date of compliance: 7/9/25