Unlabeled and undated frozen meat patties were observed in freezer two during a kitchen inspection. A staff member identified the items as hamburger patties and the Dietary Manager stated the opened bag should have been labeled and dated when opened. The facility policy provided later stated food must be stored in an appropriate method to prevent contamination.
Improper food storage and unsanitary kitchen conditions were observed in the dietary department. Standing water covered the dish room floor and extended into prep areas, while the kitchen had grease, food debris, dirty equipment, and sticky floors. The walk-in freezer and refrigerator contained multiple improperly stored items, including expired, undated, opened, and unsealed foods. The ED stated the dishwasher was broken and the RD noted sanitation concerns and that staff education still needed to be completed.
Unsanitary Kitchen With Cockroach Infestation: Live cockroaches were observed under the refrigerator, stove, and food prep counter, with dead bugs, food debris, dust, and grease buildup noted along kitchen walls, the dish room, and around the steamtable. Dietary leadership stated the cockroach problem had been present for about a year, and pest control reports also documented roaches in the break room, mop room, dish room, and drains.
A kitchen observation found a Cook preparing resident food trays with facial hair, including a mustache and sideburns, left uncovered while working near the noon meal. The Dietary Manager stated staff hair, including facial hair, was to be covered in the kitchen, and the facility policy required beard covers around exposed foods.
Food was not stored and maintained in accordance with food safety standards during two kitchen observations. Milk crates with cartons were stored directly on the refrigerator floor, the walk-in freezer had ice buildup with bread boxes stored under the unit, and the dry food storage room had dust, debris, and canned goods on the floor under shelving. Dust was also observed on the ceiling and smoke detector above a food prep table, and the DM stated ceiling and overhead vents were cleaned only when noticed rather than on a routine schedule.
Improper Food Labeling and Wet Pan Storage: A drink cart contained a pitcher of apple juice past its expiration date and an unlabeled pitcher of chocolate milk, and the DM stated the apple juice should have been discarded while the milk should have been labeled. During a kitchen tour, moisture was observed between steam table pans, and the DM stated the pans were wet and that staff were unaware they had to be dried before storage.
Uncovered food was observed on the steam table during lunch service, and a staff member touched a towel, tray tops, serving ware, and her face with gloved hands before plating food without changing gloves, including placing rolls on plates by hand. In a separate dietary pantry observation, the ice scoop for the ice machine was left sitting on top of the machine without a cover.
Dish Machine Temps Not Monitored/Recorded: The facility failed to ensure dish machine wash and rinse temps were monitored at required levels and documented for the dishwashing process. A chemical dish machine took three run attempts before reaching the minimum 140°F wash and rinse temps, and the May log showed missed entries after breakfast on one day plus multiple readings below 140°F. An employee stated he was new and had not completed the temp log, and the Administrator said she was surprised the log had not been completed daily as required.
Improper Food Handling During Meal Service: During a dining observation, multiple employees served beverages and plates while touching the eating and drinking surfaces, and one employee’s fingers were observed touching pudding and mashed potatoes while serving food. The Administrator acknowledged that placing hands on the eating surface of plates was not proper, and no policy on proper food service techniques was provided before the end of the survey.
Unlabeled food items were found in snack refrigerators on the Memory Care Unit and Station 4. A cake container with an expired best-by date, leftovers, an unopened soft drink, and a frozen treat were stored without resident names or dates, despite staff stating that family-provided food should be labeled and dated.
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 August 26, 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.