Improper Food Storage, Labeling, and Temperature Control in Dietary and Therapy Areas
Summary
Surveyors identified a deficiency related to food safety and storage practices in the facility’s dietary and ancillary food storage areas, affecting all 69 residents who received food from the kitchen. During observations, an unsealed, open-to-air bag of dried onion flakes was found, and the Dietary Manager (DM) confirmed it was not properly sealed and should have been discarded. In stand-up freezer #1, surveyors observed an undated, open bag of flour tortillas and an undated, unlabeled milkshake, which the DM acknowledged were not dated, not properly sealed, and should have been discarded. In a kitchenette refrigerator next to the main kitchen, surveyors found visibly spoiled lettuce, a package of cheese, and a box of hamburgers, all unlabeled and undated; the DM confirmed these items should have been discarded. In stand-up refrigerator #1, a bag of turkey lunchmeat and a bag of ham lunchmeat were found unsealed and open to air, and the DM again confirmed they were not properly sealed and should have been discarded. Further observations showed additional food safety issues. Stand-up freezer #2 contained two thermometers reading 48°F while storing individually packaged orange, prune, and apple juices labeled to be kept below 38°F, along with boxes of individually wrapped dinner rolls and doughnuts; the DM confirmed the elevated temperature and that the juices’ storage instructions required temperatures below 38°F. The Administrator later confirmed awareness that the freezer was under consideration for repair or replacement but was unaware that food and beverages were being stored in it. In stand-up refrigerator #4, an unsealed bag of cheese and a bag of thawed frozen strawberries dated as opened on 03/07/26 were found, and the DM confirmed the cheese was not properly sealed and the strawberries had expired. In freezer #3, a bag of chicken fingers was found unsealed and open to air, which the DM stated should have been discarded. In the therapy gym refrigerator and freezer used to store resident food, surveyors found meat and crackers labeled only with a resident name but undated, a premade salad in a takeout container unnamed and undated, a partially consumed milkshake open to air with no name or date, and an opened, unnamed, undated half-gallon container of vanilla ice cream; the Therapy Manager confirmed these items were not properly labeled and dated and should have been discarded.
Plan Of Correction
F 0812 F 0812 No resident experienced negative effects related to the unsealed box of dried onion flakes observed on 03/23/2026 @ 09:21 am. No resident experienced negative effects related to the undated bag of flour tortillas that were open-to-air and undated, observed in stand-up freezer #1 on 03/23/2026 @ 09:23 am. No resident experienced negative effects related to the undated and unlabeled milkshake that was observed in stand-up freezer #1 on 03/23/2026 @ 09:23 am. No resident experienced negative effects related to the unlabeled and undated visibly spoiled lettuce, package of cheese, and box of hamburgers observed in the kitchenette next to the main kitchen refrigerator on 03/23/2026 @ 09:27 am. No resident experienced negative effects related to the unsealed and open-to-air bag of turkey lunchmeat and bag of ham lunchmeat observed in stand-up refrigerator #1 on 03/23/2026 @ 09:39 am. No resident experienced negative effects related to the individually packaged servings of orange juice, prune juice, and apple juice; as well as individually wrapped dinner rolls and doughnuts observed in stand-up freezer #2 which contained two thermometers reading 48 degrees Fahrenheit, on 03/23/2026 @ 09:42 am. No resident experienced negative effects related to the unsealed bag of cheese and gag of thawed frozen strawberries with an open date of 03/07/2026, observed in the stand-up refrigerator #4, on 03/23/2026 @ 09:39 am. No resident experienced negative effects related to the unsealed bag of chicken fingers observed in freezer #3 on 03/23/2026 @ 09:50 am. No resident experienced negative effects related to the labeled [R] [R] meat & crackers which was undated; and a premade salad in a takeout container unnamed and undated, observed in the therapy gym refrigerator on 03/26/2026 @ 12:16 pm. No resident experienced negative effects related to the partially consumed milkshake that was open-to-air with no name of date and a half-gallon container of vanilla ice cream that was opened, unnamed and undated, observed in the therapy gym freezer. LNHA notified Medical Director on 04/06/2026 of the findings noted during Annual Survey that involved inappropriately stored foods/drinks and that no negative effects were identified in any resident related to the inappropriately stored foods/drinks. No new orders were received from Medical Director. LNHA/Designee will educate licensed and unlicensed personnel in the following: §483.60(i)(1)(2) Food Procurement, Store/Prepare/Serve-Sanitary §483.60(i) Food safety requirements. The facility must - §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. LNHA/Designee will complete daily rounds, observing food storage areas, ensuring that all items are labelled, dated, unexpired, and stored appropriately (i.e., appropriate temperature levels in refrigerators (<41 degrees Fahrenheit), freezers (at or below 0 degrees Fahrenheit). Issues will be addressed upon recognition of issue. Also, LNHA/Designee educated Dietary Manager & Therapy Director on 03/26/2026 that staff foods/drinks must be stored in separate refrigerators/freezers than residents. Further, all items in the resident's refrigerators/freezers must be dated/labeled and expiration date(s) observed. Any expired, unlabeled, or undated items are to be discarded straight away. Dietary Manager also educated on 03/26/2026 that refrigerators storing food and beverages must meet the temperature threshold of <41 degrees Fahrenheit (refrigerator) or 0 degrees or less (freezer). Freezer that was being utilized as a refrigerator was removed from service on 03/26/2026. Juices were moved to an actual storage refrigerator, within acceptable temperature range. There is adequate storage space for refrigerated and frozen items, so replacement of malfunctioning freezer is not necessary, but on or before 04/30/2026, the interdisciplinary team (IDT) will meet and discuss benefits of purchasing a new refrigerator/freezer and determine necessity. If necessary, quotes will be obtained by LNHA and purchase made. Dietary Staff will observe & record refrigerator and freezer temperatures every shift, at least twice daily to ensure temperatures are within acceptable limits (refrigerator < 41 degrees Fahrenheit and freezer at or below 0 degrees Fahrenheit). Any failing equipment will be removed from service immediately and reported to Maintenance for corrective action. Dietary Manager will be responsible for ensuring this occurs. Compliance will be determined by daily review of Dietary staff documentation by Dietary Manager. Dietary Manager audited refrigerators located in the kitchen, kitchenette, and Therapy gym on 03/26/2026. Undated, unlabeled, and expired items were discarded. Dietary Manager also verified that all refrigerators and freezers in use in the kitchen, kitchenette, and Therapy gym were within appropriate temperature range(s) (< 41 degrees refrigerator & at or below 0 freezer) on 03/26/2026. LNHA/Designee will complete audits that determine if foods & drinks are being appropriately stored and that Dietary staff are consistently and appropriately monitoring refrigerator and freezer temperatures (below 41 degrees Fahrenheit). Inappropriately stored items will be addressed straight away. These audits will be completed on at least 3 refrigerators/freezers every week x4; then as determined by QAA.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release October 8, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.