F0812

F

Widespread Food Safety, Sanitation, and Hand Hygiene Failures in Dietary Services

Carlisle, Pennsylvania Survey Completed on 02-11-2026

Penalty

No penalty information released

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.