Kitchen staff failed to maintain sanitary food prep practices and proper food storage. Observations showed debris on the refrigerator floor, an undated container of peaches, and uncovered frozen food with frost. Staff were seen touching cooked food and prep surfaces with contaminated hands or gloves, failing to perform hand hygiene between tasks, improperly cleaning and using a thermometer, handling plates with hands touching the food surface, and having loose hair outside hair nets. Interviews and prior in-services confirmed expectations for handwashing, thermometer sanitation, and hair containment.
Kitchen sanitation and dishwashing deficiencies were identified when opened food was stored in an unsealed bag in the freezer, wet pans were nested for storage, and dish machine testing was performed incorrectly with the wrong test-strip process and missing log documentation. Staff also observed a brownish-gray substance on walls, vents, sprinkler piping, the ceiling, and above the steam table and stove, and the kitchen cleaning schedule did not include those areas.
The facility failed to keep an ice machine scoop holder clean and properly stored. During a kitchen tour, the scoop holder was observed with black residue and the ice scoop was resting on it; the residue wiped away easily. The DM said the ice machine was used for residents' drinks and was cleaned weekly, while the DON and Administrator stated the scoop and holder should be cleaned daily. The facility policy required the ice scoop to be washed and sanitized daily and stored in a holder or bag.
Unlabeled and partially consumed food was found in a nourishment refrigerator/freezer, along with employee food stored in the same unit. An LPN observed multiple items without resident names or dates, including chicken, soup, candy, milk, sugar, and several freezer items such as half-eaten ice cream and tortillas. The DON, IP, and Administrator stated that resident food should be labeled and dated, employee food should not be stored there, and partially consumed food should not be returned to the fridge/freezer; the DON also stated there was no policy, cleaning schedule, or in-service evidence for the process.
Kitchen sanitation, food handling, and hand hygiene failures were observed during meal prep and service. An ice machine swipe showed brown and black specks, a food prep area had insect boxes and an ant was killed on the counter without sanitizing the surface, and a frying pot had heavy black buildup and murky oily residue. Staff also handled cups, lids, the ice scoop, and refrigerator items without hand hygiene, and a dietary aide stated they did not wash hands as often as they should.
Kitchen Food Storage and Prep Sanitation Failure: The facility failed to keep food storage and preparation areas sanitary when gray debris was observed near food prep areas, frozen meat patties lacked required dates, garlic bread sticks were left unsealed, and seasoning was kept past the opened-date timeframe. A staff member also tore open a probe wipe with his teeth, did not perform hand hygiene after touching his face and the wipe, and then used the thermometer on pureed food that was served to six residents.
Kitchen equipment and surfaces were found soiled during observation, including a drip pan with crusted food residue, a conveyor toaster with debris and grease buildup, and an oven with black, gray, and yellow-brown residue. The DM said the drip pan was cleaned weekly, the toaster was wiped after use but not taken apart for inside cleaning, and the oven was cleaned weekly; however, staff interviews and task sheets did not show cleaning tasks for the drip pans or conveyor toaster, and no in-services on cleaning and sanitization were found.
Unclean and wet food service pans were found stored in the kitchen serving residents on regular, mechanical soft, and pureed diets. During observation, a Dietary Manager found one quarter sheet pan with brown soft particles that transferred to a napkin and several other quarter sheet pans plus one full sheet pan that were wet inside. The DM said the kitchen was too small to air dry the pans, while the IP/DON and Administrator stated pans, serve ware, and dishware should not be stored wet or with food residue; the facility policy required items to be cleaned, sanitized, air dried, and properly stored.
Unsafe Food Handling and Poor Hand Hygiene During Meal Prep: A dietary staff member handled food, utensils, and blender parts with ungloved hands, placed items on an unsanitized prep table, reused a spoon after it touched a dirty lid, and performed multiple food prep and meal service tasks without hand hygiene. During lunch service, the staff member also handled tortillas and plated food with bare hands, and no hand hygiene was observed.
Hair restraints were not consistently worn during food prep when two dietary aides were observed with hair exposed outside their hair nets while preparing resident food items. One aide stated their long hair should have been fully contained, and the other aide also acknowledged all hair should have been up in the hair net. The DM confirmed all hair should be confined and that extra-large hair nets were available, while the Administrator stated dietary staff were trained on hair restraints during initial hire.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
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.