Surveyors found that nourishment refrigerators and freezers on several units were soiled with dried food debris, and multiple opened grape jelly containers were left undated and unrefrigerated despite labeling that required refrigeration after opening. Facility policies required refrigerators and freezers to be kept clean, free of debris, and that refrigerated or frozen foods be covered, labeled, and dated. Staff interviews showed that Dietary was responsible for cleaning nourishment refrigerators, that refrigerators were cleaned on a set schedule with spills expected to be wiped up by staff, and that opened jelly should have been dated and refrigerated. These practices had the potential to affect all current residents.
Food storage was not kept sanitary in the nutrition refrigerator. Surveyors observed heavy black and gray build-up inside the walk-in refrigerator, missing temperature entries for the refrigerator and no freezer temperature log, sticky residue and ice packs stuck inside the freezer compartment, and unlabeled, undated frozen food items. The DM, LPN, DON, Maintenance Director, and Administrator all stated the refrigerator and freezer compartments were expected to be cleaned and temperatures logged, and that stored food should be labeled and dated.
Improper Food Storage and Handling: Food service staff stored dented cans of apple pie filling and mushroom stems in active rotation, left dry goods open to air, and kept an undated hot chocolate container in the pantry. In the refrigerator, leftover tomato soup was left unsealed, door seals had dark discoloration, and flour and sugar bins were stored near a sink and exposed piping with visible droplets on the flour bin lid.
Unsanitary food handling and thermometer use during tray line service. The DM was observed in the kitchen without a beard restraint, and dietary staff repeatedly broke sanitary technique by touching non-food items, leaving the tray line and returning without hand hygiene or glove changes, and resting gloved hands against clothing. The food thermometer was also handled unsafely, including contact with gloved hands, a binder, and an oven mitt, and was reused without re-wiping or sanitizing the probe.
Unsanitary Food Preparation and Cross-Contamination Practices: Staff were observed handling food service tasks with gloves taken from a pocket, a cleaning cloth rinsed and wrung out instead of being kept in sanitizer, and soiled pots and sheet pans stacked over the food production table and near opened food items. The 3-compartment sink was not properly set up during the observation, and the cook, Dietary Manager, DON, and Administrator all acknowledged these practices could lead to cross contamination.
Food service safety standards were not followed when dented canned goods were found in storage and on the can rack, including cans of chicken, fruit, soup, and vegetable juice with dents on the seals or sides. Staff described a new worker learning the kitchen process, and a staff member stated dented cans were screened and placed in a dented can room, while the DON said dented cans should be thrown out immediately. During lunch tray plating, staff also failed to perform hand hygiene.
Mold was observed inside the kitchen ice machine on repeated surveys, and the facility’s cleaning records did not include the ice machine or show consistent documented cleaning. Staff gave conflicting accounts of how often the ice machine was cleaned. Surveyors also observed two aides in the kitchen with hair nets that did not fully cover their hair while one was preparing tea and stirring food, and leadership confirmed hair nets should cover all hair.
Surveyors identified that the facility failed to follow its own food storage and employee sanitary practices policies, potentially affecting all residents receiving meals. In dry storage and the walk-in freezer, multiple food items, including large containers of mayonnaise and relish, au gratin potatoes, cereal, coffee creamers, frozen peas, and biscuits, were found opened or removed from original packaging without required received or opened dates. A dietary aide was observed preparing food while wearing a bonnet that did not fully restrain her hair, leaving bangs and side hair exposed. The dietary manager, dietary staff, department head, and administrator all acknowledged in interviews that policy requires all food to be dated when received and when opened, and that anyone entering the kitchen must wear hair restraints that fully contain all hair to prevent contamination.
Food storage and sanitizer practices were not maintained in accordance with facility policy. Surveyors found undated cans, unlabeled and undated packaged foods, a clear container of food that was not labeled or dated, and cereal containers in a serve kitchen without labels or dates. Surveyors also found the kitchen sanitizer bucket lacked documentation of when the solution was checked or changed, and the Chef stated this was not documented.
Cook1 failed to follow proper hand hygiene and glove-use practices while preparing and serving food. He touched his beard cover and ball cap with gloved hands, handled food and serving items with the same soiled gloves, used his hands instead of tongs to place bread on trays, and later rinsed his hands without soap before returning to meal service. The DON, District Manager, and Administrator stated staff should wash hands and change gloves after contamination or touching the face, hair, or person.
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