Improper Hand Hygiene During Food Prep: A cook wore gloves while handling cucumbers, touched a garbage can lid, and then continued handling food without removing the gloves or washing her hands. She later changed gloves and resumed cutting cucumbers, then removed the gloves and washed her hands. The DM and the cook both stated hand hygiene was expected before gloving and after glove removal.
Dish Machines Used Before Reaching Required Temperatures: Two dish machines did not reach the required minimum wash and rinse temperatures before dishes were washed. A cook in the main kitchen ran dishes through a machine that reached only 142 degrees for wash and 164 degrees for rinse, and another cook in the second-floor kitchen used a machine that reached 147 degrees for wash and 177 degrees for rinse. Staff stated the machines needed to be run a couple of times to get up to temp, and the admin confirmed the required minimums were 150 degrees for wash and 180 degrees for rinse.
Unsanitary conditions were observed in two neighborhood pantries when dishwashers had thick biofilm and food particle buildup on the inner doors, one handwashing sink had grayish buildup, and a wall-mounted fan had visible dust buildup while blowing air toward the food service area. Staff stated the dishwasher and sinks were supposed to be cleaned daily, but the buildup was not known to the FSW-FA, CDM, or DSS, and there were no checklists showing when cleaning tasks were last completed.
Improper hand hygiene and glove use occurred during meal service when two cooks handled ready-to-eat foods with contaminated gloves, one cook discarded a glove into an unlidded trash container beside food items, a restorative therapy staff member did not wash her hands between feeding residents and eating her own meal, and a CNA/CMA handled a clean juice cup with soiled gloves before placing it in the refrigerator. The DON and administrator confirmed hand hygiene and glove changes were expected in these situations.
Failure to Maintain Hand Hygiene During Meal Prep: During lunch service, a cook dropped a butter container lid on the floor, picked it up, and continued plating food without hand hygiene. She also coughed into her hand while holding a resident plate, drank from her personal cup placed on a food transport cart, and kept preparing resident meals without washing or sanitizing her hands. The ADM and DM gave conflicting views on the beverage placement, but the DM stated the cart top was not a designated space for staff drinks.
A dietary aide failed to follow hand hygiene and food safety practices during meal service in the Central dining room. She touched her face, hair, pants, and a resident, then handled and served resident food without washing or sanitizing her hands, used bare hands to apply butter to a resident’s bread, washed her hands for only about 4 seconds, and put a milk lid back on a container after it fell on the floor. The DM confirmed the expected hand hygiene and food handling practices, and the facility policy required handwashing for at least 20 seconds before and after handling food and resident contact.
Food storage and sanitation practices were not followed in the kitchen and food storage areas. Dented #10 cans were found in dry storage, dust was observed on a ceiling conduit and on a fan blowing into the clean dishwashing area, and residue covered the dishwasher and nearby wall. A FSA carried clean items and frozen desserts against her apron and later used her hand to open a trash can lid despite a step pedal being available; the CDM and administrator acknowledged the deficient practices.
Unsafe food temperatures and missing hair restraints were observed during meal service. In one kitchenette, egg salad sandwiches were initially 45 F and later 50 F, and milk on a resident tray was 60 F; multiple staff, including the DON, RN supervisor, MDS coordinator, CNAs, and others, washed hands near uncovered food without hair nets or hair restraints. In another kitchenette, uncovered food was in the steam table while the SSD, staffing coordinator, medical records director, and RN/MDS coordinator washed hands without proper hair restraints.
Food service sanitation and storage practices were not followed in the kitchen and activity room kitchenette. Staff observed a dirty popcorn machine, buildup in the dishroom sink and beverage dispensers, debris in the freezer, raw meats stored with liquid pooling in the cooler, and bulk ingredients left undated with a spoon stored in sugar. The activity room dishwasher was used for resident cups and dishes even though it did not reach sanitizing temperatures and the detergent pods did not provide chemical sanitization. During meal service, a CNA touched resident wheelchair equipment and then poured water for three residents without performing hand hygiene.
Surveyors identified multiple food safety and sanitation failures, including staff using the same disposable gloves to handle surfaces and then directly touch RTE food and dishware, and a dietary aide preparing deli sandwiches for staff and residents without changing gloves or performing hand hygiene after leaving and re-entering the kitchen. Thermometer probes were stored in sanitizer containing food debris and were wiped on a cloth instead of being sanitized with alcohol wipes before checking food temperatures. The kitchen and walk-in cooler had heavy dust on vents, fans, ceilings, and light fixtures, and the commercial dishwasher had significant food scum and limescale buildup, with many missed deliming sessions and numerous undocumented dish machine temperatures despite policy requirements. Potentially hazardous foods were left at room temperature for extended periods, raw bacon was stored above RTE mashed potatoes, frozen beef patties were left uncovered in the freezer, and multiple expired or visibly spoiled items, including flavor extracts, food coloring, coffee syrups, relish, and dressing with apparent mold, were found in storage without appropriate dating or rotation.
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