Improper Dishwashing and Sanitizer Monitoring Leading to Immediate Jeopardy
Summary
The deficiency involves the facility’s failure to ensure that dishwashing equipment and manual warewashing processes were maintained and operated according to manufacturer specifications and facility policy, resulting in improper sanitation of dishware, cookware, and utensils. Surveyors found that the dish machine’s hot water booster had not been functioning since a snowstorm, and the machine had been converted by the vendor from a high‑temperature to a low‑temperature chemical sanitizing system. Despite this change, there was no evidence that staff were monitoring or documenting dish machine temperatures or chemical sanitizer concentrations. The last recorded entry on the dish machine temperature log was dated 12/31/25, and the acting Food Service Director (FSD) could not demonstrate how to check or interpret chemical concentrations, nor locate appropriate test strips. The dish machine vendor later informed the facility that the chemical sanitizer attached to the dish machine was expired and not properly sanitizing dishware. Surveyors also observed significant deficiencies in the use of the three‑compartment sink for manual warewashing. A dietary staff member was seen washing pots and pans in the first sink and then placing them directly into the third sink containing sanitizer, skipping the required rinse step in the second sink. The staff member stated, "I don't check for anything" and was unable to explain the correct setup or process for the three‑compartment sink. There was no log documenting sanitizer concentration checks for the three‑compartment sink, and the acting FSD could not initially locate test strips or provide policies beyond a poster above the sink. When the acting FSD attempted to test the sanitizer in the three‑compartment sink, she first used chlorine test strips incorrectly (wrong contact time and no color change), then later used the correct quaternary test paper and obtained a reading between 200–400 ppm, but still reported there was no documentation system in place. During meal service observations, surveyors noted that most residents were being served meals on disposable dishware and utensils, while some residents continued to receive meals on regular washable dishware and utensils. On two nursing units, breakfast trays included both disposable and regular dishware, and used meal trays in the hallway contained a mix of ceramic and disposable items. The acting FSD stated that disposable dishware was being used for most residents because the dish machine was not reaching the required sanitizing temperature, but that two residents who refused disposables continued to receive meals on regular dishware and washable utensils. Nursing staff on the units could not explain why disposables were being used and deferred questions to kitchen staff. The LNHA gave conflicting explanations, at one point stating the dish machine had been working and disposables were used due to an influx of evacuated residents, and at another point acknowledging that the machine had been converted to low‑temperature chemical sanitizing. The LNHA was not aware that sanitizer levels needed to be monitored with the low‑temperature setup, and neither he nor dietary staff could provide documentation that sanitizer concentrations were being checked or recorded. These combined failures in equipment maintenance, monitoring, staff competency, and adherence to written policies led to an Immediate Jeopardy determination related to food safety and sanitation for all residents. The facility’s written policies required specific wash and final rinse temperatures for high‑temperature dishwashers and specified sanitizer concentration requirements for low‑temperature dishwashers, but there was no policy guidance on converting from high‑temperature to low‑temperature chemical sanitization when the booster failed. The dish machine failure policy directed the use of disposables when the dishwasher was out of service, but did not address monitoring of chemical sanitizers or procedures for a low‑temperature system. The Safety Data Sheet for the low‑temperature sanitizer attached to the dish machine described it as a hazardous chemical capable of causing eye and skin burns, respiratory irritation, and harm if swallowed, underscoring the need for correct use and monitoring. Despite this, staff were unable to demonstrate proper testing of sanitizer concentrations, did not maintain logs, and in at least one instance did not follow the manufacturer’s required wash‑rinse‑sanitize sequence in the three‑compartment sink. These documented observations and interviews formed the basis of the cited deficiency for failure to procure, prepare, and serve food under sanitary conditions and in accordance with professional standards.
Removal Plan
- The LNHA contacted the dish machine vendor.
- The LNHA re-educated the Cook, dietary cooks, and dietary aides regarding kitchen sanitation to ensure proper handling of pots, pans, cutlery, and dishware.
- The LNHA re-educated dietary staff on proper use of the dish machine and the three-compartment sink to ensure washing, rinsing, and sanitizing are done correctly, in the correct order, with proper temperatures and sanitizing.
- The LNHA re-educated dietary staff on the importance of documenting sanitizer test results on flow sheets with each use.
- Return demonstrations/competencies were completed by the pot washers and observed by the LNHA and interim FSD.
- All dietary staff will be re-educated and required to complete competencies and return demonstrations prior to working.
- The LNHA re-educated the Cook and dietary staff regarding the use of disposables/paper goods in the event the dishwasher is out of service.
- All necessary dishware was immediately re-sanitized.
- Signs in English and Spanish with instructions for sanitizer use were posted by the dish machine and three-compartment sink.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to use beard restraints during food prep and meal service was observed when two cooks with visible facial hair handled and checked food without beard coverings. One cook said he was unsure a beard restraint was required, and the other said staff never wore them. The KL stated beard restraints were required, but none were available on the hygiene supply shelf, which contained gloves, hair restraints, and aprons.
Food Storage and Personal Hygiene Deficiencies: A Cook was observed preparing food without required hair or beard covering, and multiple food items in the freezer, refrigerators, and kitchenette were found without open dates. Surveyors also found expired Greek yogurt in the walk-in refrigerator. The CDM stated items should be labeled with open dates and expired items discarded, while the facility policy required food service staff to wear a hair net or appropriate hair covering during food production and clean-up.
Improper Thawing of Frozen Chicken: Staff thawed frozen breaded chicken in a 3-compartment sink without cold running water instead of using an approved defrosting method. A Cook said she removed the chicken from the freezer about an hour earlier, and the DM confirmed the chicken was thawed in the sink after staff forgot to remove it from refrigeration earlier. The facility's policy required thawing in refrigeration, under running water, in a microwave under specific conditions, or as part of the conventional cooking process.
Unlabeled refrigerated food items were observed in the kitchen, including red gelatin, sausage patties, and two pitchers of tea. The DS confirmed the items were not labeled and stated the tea was not labeled before being served at lunch, while the ADM stated all food in the refrigerator should be labeled and dated per facility policy.
Dietary staff failed to store, prepare, and serve food in a sanitary manner. Observations showed lemonade left on top of an ice machine, oatmeal placed on a serving area, sausage links without a date or label, chicken stored above potatoes without a date, and a refrigerator without a thermometer. During meal service, staff touched the inside of bowls and handled grilled cheese sandwiches and other food items with gloved hands without changing gloves or performing hand hygiene.
Ice Machine and Water Filter Not Properly Cleaned: An observation found black and brown substance on the ice machine's water curtain guard and a dark brown water filter behind the machine. The dietary manager was unsure when the ice machine was last cleaned or how often the filter was changed, while the ADM believed it had been checked and cleaned within the prior week. The maintenance supervisor said he was responsible for cleaning and maintaining the machine, changed the filter monthly, visually inspected it weekly, and deep cleaned it in July, but may have missed part of the guard.
Failure to Use Beard Restraints During Food Preparation
Penalty
Summary
The facility failed to ensure the proper use of beard restraints during food preparation and meal service. During observation and interview, one cook was seen taking the temperatures of oatmeal and scrambled eggs while having gray whiskers covering his chin and lower cheeks, and he was not wearing a beard restraint. When asked about beard restraints, he stated he was not sure he was supposed to wear one and said no one in the kitchen wore beard coverings and he would not know where to find one if required. A second cook was observed stirring separate pots of vegetables and chicken to be used in soup while having black whiskers covering his chin and cheeks and not wearing a beard restraint. He stated kitchen staff never wore beard coverings and the facility had never required this, adding that they probably should be wearing them. The kitchen lead stated he thought beard restraints were required and identified a shelf for hygiene supplies, but the shelves contained disposable gloves, hair restraints, and aprons and did not contain beard restraints. He stated the facility did not appear to have any beard coverings and that he would include them on his next order. A policy dated 6/19/19 directed staff to wear hair coverings and keep mustaches, sideburns, and beards neatly trimmed.
Food Storage and Personal Hygiene Deficiencies
Penalty
Summary
The facility failed to meet professional standards for food storage and personal hygiene during observations of the kitchen and refrigeration areas. On 8/10/26 from 8:10 AM to 9:30 AM, Staff B, the Cook, was observed not wearing a hair or beard net while working. During the same observation, Freezer #1 contained multiple food items without open dates, including cheese ravioli, salmon patties, onion rings, sweet potato fries, wings, and chicken strips. The double-door refrigerator also contained numerous undated items, including several dressings and sauces, lettuce, lime juice, stuffed queen olives, banana pepper rings, soy sauce, teriyaki sauce, sweet and sour sauce, and red hot wing sauce. The walk-in refrigerator contained additional items without open dates, including strawberry yogurt, lettuce, almond frosting, pepperoni slices, ice cream, and tilapia. The walk-in refrigerator also contained five 32-ounce containers of Greek yogurt that had expired on 7/29/26. On 8/11/26 at 10:36 AM, Staff B was observed wearing a baseball cap and beard net while preparing food. Later that day at 11:25 AM, the refrigerator in the small kitchenette contained undated whole milk, fat-free milk, and 2% milk. Staff A, the Certified Dietary Manager, stated that items were expected to be labeled with an open date and expired items were to be discarded once expired, and she said she would need to review the facility policy regarding hair and beard nets because she believed short hair did not require a hairnet. The facility’s personal hygiene policy required food service staff involved in food production and clean-up to wear a hair net or appropriate hair covering, and the labeling and dating policy required all prepared, opened, stored, or repackaged food items to be properly labeled and dated, with improperly labeled, undated, expired, or unidentifiable items not served and discarded.
Improper Thawing of Frozen Chicken
Penalty
Summary
The facility failed to thaw frozen chicken using an approved method of defrosting. During an initial kitchen walkthrough, surveyors observed 3 bags of frozen breaded chicken leg drums sitting in a 3-compartment sink without cold running water. A later observation showed the same chicken bags placed in a basin inside the 3-compartment sink, again without cold water. Staff A, Cook, stated she had removed the chicken from the freezer about an hour earlier and was thawing it in the sink. The lunch menu for that day documented chicken drumsticks. The Dietary Manager acknowledged that Staff A thawed the frozen breaded chicken in the 3-compartment sink. The DM stated kitchen staff had forgotten to remove the chicken from the refrigerator earlier and reported that staff were expected to thaw chicken in the refrigerator or under cold running water. The DM also noted a small hole in the chicken bag and stated staff did not want the breaded chicken to get wet. The Administrator stated dietary staff were expected to thaw frozen chicken in the refrigerator or under cold running water. The facility's Food Preparation Policy required frozen meats and leftovers to be thawed only by approved methods, including refrigeration, running water, microwave under specific conditions, or as part of the conventional cooking process.
Unlabeled refrigerated food items
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 the initial kitchen tour on 08/11/2026 at 09:35 a.m., surveyors observed a bowl of red gelatin with no label, a bag of sausage patties with no label, and two pitchers of tea with no label in the refrigerator. During interviews, the DS confirmed that the gelatin and sausage patties were not labeled and stated she did not know the tea needed to be labeled before being served at lunch in about an hour and a half. She stated the gelatin, sausage patties, and tea were not labeled when placed in the refrigerator and that all items should be labeled when placed there. The ADM also stated that all food in the refrigerator should be labeled and dated, and the facility policy titled Storage of Frozen and Refrigerated Foods required cold or frozen foods in the refrigerator to be labeled with the date opened or prepared, time, and expiration or use-by date.
Unsafe Food Storage and Improper Food Handling
Penalty
Summary
The dietary department failed to store, prepare, and serve food in a sanitary manner during kitchen observations. During an initial tour, a pitcher of lemonade was observed sitting on top of the ice machine, a bowl of oatmeal was placed on top of the serving area for plates, and a clear bag of sausage links was sitting on a plastic cart without a date or label. Staff stated the sausage had been opened the day before and should have been dated and stored in the refrigerator when not in use. In the walk-in refrigerator, a plastic container covered with aluminum foil and labeled chicken had no date and was stored inside another pan with ice on the second shelf above potatoes. Staff stated the chicken would be used the next day and should have been stored on the bottom shelf and dated before being placed in the refrigerator. A refrigerator in [NAME] Hall did not have a thermometer, and staff confirmed none could be located. During meal service, staff were observed touching the inside of bowls while grabbing multiple bowls at a time, and another staff member touched grilled cheese sandwiches with a gloved hand while flipping them and then returned to food handling after touching a cooler and handling cheese without changing gloves or performing hand hygiene. The assistant dietary manager stated the lemonade should have been stored in the cooler, the sausage should have been labeled and dated, the chicken should have been dated and stored on the bottom rack, the refrigerator should have had a thermometer, and staff should have handled bowls by the outside and washed hands or changed gloves when handling food.
Ice Machine and Water Filter Not Properly Cleaned
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen reviewed. During an observation on 08/10/2026 at 9:30 AM, the ice machine in the dining area had a black and brown substance on the white plastic water curtain guard above the ice, and the water filter behind the machine was dark brown in color. The dietary manager stated she was responsible for the kitchen area but was not sure of the cleaning timeframe or when the ice machine was last cleaned, and she did not know how often the water filter was changed. The administrator stated the maintenance supervisor was responsible for maintaining the ice machine and water filter and believed it had been checked and cleaned in the last week, but she needed to ask for the cleaning schedule and filter change dates. The maintenance supervisor stated he had been responsible for the ice machine for over a year, changed the water filter monthly and as needed, visually inspected it weekly, and deep cleaned the ice machine in July 2026. He stated he may have missed the small section of the guard with the dark substance. The facility policy required cleaning and disinfecting ice machines and ice storage chests according to the manufacturer's instructions, and the Manitowoc service manual stated the ice machine should be cleaned and sanitized every six months, or more often if needed based on water quality.
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