Kitchen sanitation and equipment maintenance failures were observed in the main kitchen. Surveyors found moldy cucumbers in the cooler, a freezer with dripping condensation and ice buildup, soiled utensils, drain flies, heavy debris on equipment and floors, disintegrated wiping cloths, and a steamer oven leaking boiling liquid. The box compactor area was piled with empty boxes, and interviews showed cleaning duties were divided, logs were not being completed, and kitchen cleanliness was not being documented.
Food service sanitation and hand hygiene were not maintained when a liquid drained from kitchen sink plumbing during tray line, and a Dietary Aide cleaned it up, changed gloves, and continued handling food without washing hands. The ice scoop was stored in ice, the ice machine had visible debris with incomplete cleaning documentation, and the dumbwaiter was dirty while uncovered clean laundry and used meal trays were transported through it.
Surveyors found multiple food safety lapses in the kitchen, including opened and unlabeled food items in the walk-in refrigerator and freezer, dirty food prep and sink areas, and a nonfunctioning handwashing sink with grime and a spoon in it. The automatic dishwasher’s final rinse temperature was observed below the required level, and records showed repeated low rinse temperatures across multiple meal services. Staff and leadership acknowledged the labeling and equipment issues, and vendor records documented prior dishwasher repairs and ongoing maintenance problems.
Food was plated and served with hot items falling below safe temperatures while meals were delayed and held on sterno setups. One cook was plating trays alone, a sterno burner went out during service, and multiple foods measured below 135 F, including a test tray with Salisbury steak, potatoes, and vegetables at 110 F, 118 F, and 100 F. Staff and residents reported that meals often arrived cold or lukewarm, and the FSD stated the kitchen was under renovation and meals were being catered and modified on-site.
Surveyors found that the facility did not follow its own kitchen cleaning schedule, with damaged and ajar ventilation hood filters over the cook top, heavy grease and food debris on the oven and cook top surfaces, and a broken floor section under a steamer containing standing water and food debris. These unsanitary conditions persisted on re-observation. During meal service, disposable plates and utensils were used on the tray line for multiple units because of a shortage of non-disposable plates and silverware, which the Food Service Director attributed to missing items and back-ordered replacements. A resident reported that it would be preferable to have real silverware and plates during meals.
Unlabeled, expired, and personal food items were found in Unit A and Unit D servery refrigerators, along with soiled refrigerator surfaces and food debris on the floor. Staff interviews confirmed that opened items should be dated, discarded within the required time frame, and kept separate from personal items, and that the servery areas should be clean and sanitary.
Surveyors identified multiple failures in food storage, sanitation, and meal service, including a main kitchen reach-in cooler operating above safe temperatures with improperly cooled eggs and other cold foods, and black residue on cooler door gaskets and a walk-in milk cooler ceiling crease in both the main kitchen and a unit pantry. There was no documented kitchen cleaning schedule, no record of gasket or ceiling cleaning, and staff gave conflicting accounts of who was responsible for cleaning refrigerators and gaskets. During meal service, a food service worker attempted to provide a resident with a tray taken from a cart containing dirty and uneaten trays, without a tray ticket, before acknowledging this should not be done and removing the tray.
Surveyors found multiple food storage and labeling violations, including unlabeled almond milk in a walk-in refrigerator, cooked chicken and vegetables held beyond the facility’s 72-hour limit, and a defrosted container of whole eggs without a defrost date. In a pantry refrigerator, several 4-oz fruit and pudding cups were undated, illegibly dated, or past the facility’s allowed holding time, despite policies requiring all perishable and pantry-refrigerated items to be labeled, dated, and discarded after 72 hours. The Food Service Director and dietary staff confirmed the 72-hour standard and labeling requirements and acknowledged that daily rounds intended to remove outdated or improperly labeled items did not prevent these issues.
The facility failed to follow its own food storage and handling policies, resulting in residents receiving expired or improperly held food and beverages. A resident reported curdled, off‑tasting milk that was past its expiration date. Surveyors observed multiple opened, unlabeled, and undated food items in the main kitchen and unit pantries, along with several clearly expired products, including milk and cooked meats. They also found personal and resident food in unit refrigerators and freezers that was not labeled or dated as required. During meal tray assembly, milk portions were left out and measured at temperatures well above the required 40°F or less, and several residents complained that the milk tasted sour even though the cartons were within date. Staff interviews confirmed that policies required labeling, dating, discarding expired items, and maintaining proper temperatures, but staff could not explain why expired and unlabeled foods remained or why milk was allowed to warm during tray preparation.
Food Storage and Preparation Deficiencies: Surveyors observed unlabeled prepared foods and condiments in refrigerators, expired bread in dry storage, personal food stored in a kitchen freezer, beverages placed in the walk-in freezer to cool, and pork thawing in standing water with carrots floating in the water and the meat not secured in packaging. The FSD stated several items had been prepared earlier that day but had not yet been labeled, and that the pork was being thawed for lunch service.
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 July 29, 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.