Widespread Food Safety, Sanitation, and Hand Hygiene Failures in Dietary Services
Summary
The deficiency involves the facility’s failure to store, prepare, distribute, and serve food in accordance with professional standards and its own policies for food safety and sanitation. Facility policies required proper food storage, labeling, dating, covering of foods, use of utensils to avoid bare-hand contact, routine cleaning and sanitizing of equipment, and appropriate employee sanitary practices, including hair coverings. Surveyors observed multiple violations of these policies in the main kitchen, nourishment refrigerators on two units, and during tray line and tray pass observations. The Nursing Home Administrator (NHA) acknowledged that foods should be labeled, dated, and stored properly, that cleaning should be completed routinely, and that sanitary policies should be followed. In the kitchen, surveyors observed widespread cleanliness and storage issues. The ice machine had pink residue on a plastic guide and heavy dust on its water filter and hose. The shelving unit and drawers under the coffee maker were soiled with coffee grounds and spills, with dried coffee in contact with clean cup lids and juice caps stored with those lids. Food debris, including what appeared to be a piece of hot dog, was found on the floor between the ice machine and coffee stand. The beverage reach-in refrigerator contained multiple opened beverages (prune juice, thickened juices, milk) without open dates, an unlabeled red beverage that had spilled inside the unit, and a soiled base and surrounding floor. Additional issues included dusty and debris-contaminated lid storage bins, blender bases with food debris, a thickener bin with the scoop stored inside and a soiled lid, yellow powdery residue in a utensil drawer, heavily soiled stove and floors, food debris under and around equipment, soiled pot holders, and a mixer and dish room walls with food debris. The can opener had heavy black buildup despite policy requiring daily washing and sanitizing, and some spices were past the facility’s stated discard timeframe. Dish racks and dishes were stored upright and uncovered with visible debris, and utensils were found with dried residue and lying on a soiled counter used as a drying area. Test strips for the three-compartment sink included an expired bottle. Food storage and labeling deficiencies were also documented in the walk-in refrigerator, freezer, dairy cooler, dry storage, and nourishment refrigerators. In the walk-in units, surveyors found multiple opened items without dates (milk, thickened milk, juices, frozen blueberries), unlabeled or undated prepared foods (chicken and rice soup, meat patties, cheese slices), items past their discard dates (ham, pork), unsecured or partially unwrapped products, and an unlabeled bag of frozen food that staff identified only after questioning. Dry storage logs were incomplete, with no temperature entries after a certain date, and there was no thermometer or temperature log in a second dry storage area containing cereal and creamers. Opened bakery items and other dry goods (rolls, pecans, Craisins, pancake mix, sprinkles) lacked open dates or were unsecured. On the units, nourishment refrigerators contained opened thickened beverages and supplements without open dates, multiple unopened beverages and frozen items without resident names, and a cloth-covered ice pack labeled with a resident’s name stored on the same shelf as food. One nourishment refrigerator lacked a temperature log, and its freezer had no thermometer. Surveyors also identified failures in employee sanitary practices and dishwashing temperature monitoring. In the kitchen, the Dietary Manager handled expired hand sanitizer bottles while wearing gloves, discarded them, and then immediately returned to food preparation and continued making a quesadilla with the same gloves until stopped by the surveyor; he then acknowledged the issue and washed his hands only after being prompted. During tray line observation in the main dining room, a dietary aide wore a baseball cap with exposed hair and repeatedly used a gloved hand to touch and guide salmon patties, green beans, and noodles onto plates while also handling paper meal tickets. The aide then placed both gloved hands on the lid of a soiled linen hamper and returned to serving food without changing gloves or washing hands, which he confirmed he had been about to continue doing. During tray pass on one unit, approximately 20 meal trays were observed with small cups of pears that were uncovered while being transported through hallways, and the Dietary Manager stated that lids were available but not used. Review of the dishwasher temperature logs showed repeated failures to meet the required minimum final rinse temperature of 180°F and, on at least one occasion, a wash temperature below the required 140°F. Across multiple dates in November, December, and January, final rinse temperatures were documented in the 150s and 160s, below the facility’s stated minimum. One day’s wash and rinse temperatures were scribbled out, and no additional information was provided regarding these temperature deficiencies. Kitchen cleaning logs requested by surveyors were not provided. In interviews, the NHA and Director of Nursing confirmed that staff should not have returned to food preparation with contaminated gloves or touched food directly, and the NHA acknowledged that dietary staff had been refilling and continuing to use expired hand sanitizer bottles and that the kitchen could have followed sanitary guidelines better.
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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