Meal trays were left in residents’ rooms for extended periods after delivery, including breakfast and lunch trays that remained unrefrigerated for hours. Surveyors observed food still in rooms well after meals were served, and the DM found breakfast items such as milk and pancakes in the unsafe temperature range, with an uncovered pastry also observed with a fly on it. Staff, including the CNA, DM, NHA, DON, and other leadership, stated trays were left so residents could eat at their own pace and were not removed until the next meal was delivered.
Kitchen food storage and sanitation deficiencies were identified when unlabeled and undated fruit cups and pies were found in the refrigerator, the ice scoop holder and microwave had visible residue and food buildup, and raw beef was stored above a prepared salad mixture on a utility cart. Staff and the DM acknowledged that prepared foods should be labeled and dated, equipment should be kept clean, and raw meat should be separated from ready-to-eat foods to prevent cross-contamination.
Improper Hand Hygiene and Glove Use During Meal Prep: A dietary aide repeatedly handled ready-to-eat foods, meal tickets, plates, bread bags, and utensils with the same single-use gloves while preparing and serving lunch items, without washing hands or changing gloves between tasks. The DM and RD stated staff should wash hands and change gloves when changing tasks or after leaving the task, and noted recent hand hygiene and glove-use training.
Food service staff failed to follow hand hygiene and glove-change practices during meal service, including changing gloves without washing hands, touching a cell phone with a gloved hand, and moving from temperature documentation to meal service without hand hygiene. Multiple TCS foods were left out on prep tables and the meal service table without ice, with temperatures ranging from 48.9 F to 63.1 F. The main kitchen and dishroom also had damaged floors, a window above a prep table with peeling tape and dust/debris, and dirty flour containers with residue on the scoops.
Kitchen Sanitation and Food Storage Deficiencies: Surveyors observed food debris, crumbs, residue, and improperly stored items in the main kitchen and a satellite kitchen, including items on the floor and beneath shelving and equipment. Surveyors also found expired, uncovered, and unlabeled food in refrigeration areas, including sauces, salmon, vegetables, beef, pork sauce, sweet potatoes, and cheese past its good-through date. Staff stated that food and kitchen areas should be kept clean, and prepared foods should be covered, labeled, and dated before storage.
Staff failed to follow hand hygiene practices during meal service in the kitchen and dining room. A cook and a dietary aide handled refrigerators, cabinets, food, and equipment while changing gloves or continuing with the same gloves without washing hands, and a resident assistant and CNA assisted two residents at one table and two more at other tables while touching wheelchairs, utensils, and beverage cups without hand hygiene. Interviews confirmed staff knew hand hygiene was required before food handling, after glove removal, and after touching potentially contaminated items.
Hand hygiene was not followed during meal service and tray delivery. In the kitchen, a cook handled food, trash, and a thermometer with gloved hands without cleaning hands between task changes, and the DM touched her shirt collar and cheek with a gloved hand, removed gloves, and did not perform hand hygiene before handling hot food. During room tray delivery, a CNA repeatedly handled trays, water cups, and resident meals without hand hygiene between rooms and tasks, and the DM stated staff should clean hands after each task change and before new gloves are donned.
Surveyors found unsanitary conditions in the kitchen, including food debris and grease buildup under the steam table and oven area, debris around the steam table wheels, and dirt buildup in the ice machine. They also observed food items left uncovered or unlabeled and multiple refrigerated items past their discard dates, while staff interviews showed inconsistent practices for cleaning, labeling, dating, and discarding food items.
Improper Hot Food Holding During Meal Service: During dinner meal service, a cook checked steam table food and found pureed beef and hamburger patties at 127 degrees F, below the required hot holding temperature. The cooks then served the food without reheating it, and meal plates were assembled with the food still at the inappropriate temperature.
Kitchen Sanitation and Food Labeling Deficiencies: Surveyors observed dust on the tray line shelf with clean pans and lids stored on it, rust and stains on kitchen fixtures and ventilation surfaces, a hole in a door frame, a missing handle on the chemical storage room door, stained sink areas, dirty rags stored under the sink, ceiling stains over the stove, and missing floor tiles in the dishwashing room. Surveyors also found several opened sauces and dressing in the walk-in refrigerator that were not dated, despite the facility policy requiring foods to be labeled and dated.
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