Surveyors found that the facility did not maintain sanitary conditions in the walk-in freezer and ice machine area. Ice buildup on freezer lines was encroaching on a box of burritos, and an ice scoop holder attached to the ice machine contained standing water with two scoops resting in it and no visible drainage. The Dietary Manager acknowledged the recurring ice buildup and reported that the standing water issue had not previously been raised. These practices did not follow the facility’s policies for food safety, storage, and ice machine preventative maintenance and had the potential to affect 46 residents who consumed food from the kitchen.
A nutritional aide was observed preparing and handling resident meal trays and assisting with food preparation while wearing a hair guard that did not fully contain her hair, leaving bangs exposed and not properly restrained as required by FDA Food Code. The Nutritional Services Director acknowledged she had not noticed the improper hair restraint use and confirmed that staff hair should be completely secured in accordance with facility food safety standards.
Surveyors found that kitchen staff failed to follow food storage and labeling standards, including multiple dry goods with past or missing use-by dates, undated and improperly sealed refrigerated and frozen items such as cut vegetables, meats, and prepared salad dressings, and a tray where leaking salami was stored with cheese. An allegedly clean skillet was observed with encrusted food on its surfaces. The Food Service Manager acknowledged that items should have been sealed, dated, and cleaned in accordance with the Idaho Food Code.
Surveyors found that an ice machine used to produce ice for residents had a black, blackish brown residue along its interior metal plate, indicating inadequate cleaning of this food-contact surface. The Dietary Manager confirmed the residue and stated that maintenance was responsible for cleaning the rented ice machine, while Plant Operations Personnel confirmed the black substance and reported that the rental company performed quarterly cleaning and monthly maintenance. These findings showed that the ice machine was not cleaned often enough to prevent buildup of soil or mold, in violation of FDA Food Code and SOM requirements.
Surveyors found that kitchen staff failed to follow professional standards for food storage, labeling, and distribution, including opened refrigerated and frozen items without proper use-by dates and undated baked goods in the pantry. Dietary trays delivered to resident rooms contained uncovered food items such as gelatin and sliced cake, and the dietary manager acknowledged not being aware that all tray food must be covered. Inspectors also noted that the same daily cleaning log was reused and marked completed for an entire week instead of being replaced, as confirmed by the dietary aide and dietary manager.
Surveyors found that food service staff failed to follow basic sanitation and labeling practices, including a diet aide repeatedly entering and working in the kitchen without proper hand hygiene and with an improperly worn hair net. In the main freezer, icicles from the air condenser unit were melting and dripping into an open box of frozen egg patties. Resident refrigerators contained brown streaks and spots, and both staff and resident food items were stored without required labels or dates, with some frozen meals marked only by room number. Dust buildup was observed on a refrigerator air condenser unit, and the dietary manager acknowledged that both cleaning and monitoring of equipment and food labeling were not being performed as required.
Surveyors found that dietary staff prepared and served food while wearing rings and bracelets and performed hand hygiene without removing this jewelry, contrary to FDA Food Code guidance that such items can harbor soil and pathogenic organisms. In addition, kitchen cutting boards were observed to have dark stains embedded in the plastic grain, indicating they were scratched, difficult to clean, and potentially capable of harboring microorganisms. These practices affected all individuals consuming facility-prepared food and created a risk of food contamination and food-borne illness.
Surveyors found that kitchen staff failed to follow FDA Food Code and facility policy for food storage, labeling, and sanitation. Ready-to-eat salads remained in the walk-in refrigerator beyond their intended use date, and chocolate pieces in the walk-in freezer were stored on an uncovered, unlabeled, and undated cookie sheet. Supposedly clean muffin pans on the storage rack were encrusted with buildup on both sides, and the area around the food prep sink, including the drain grate and floor-wall junctions under counters and sinks, was heavily soiled with dirt, food, and grime. These issues affected all residents receiving meals prepared in the kitchen.
Surveyors found multiple food service deficiencies, including outdated spices, undated cooking oil, and frozen items without use-by or opened dates, as well as opened breakfast biscuits without dates and snack items stored on the floor. Refrigerator temperature logs showed repeated readings above the acceptable range with no documentation that these were reported, despite policy requirements. In the resident snack refrigerator, food containers lacked date labels even though posted instructions required both name and date, and the DNS confirmed this expectation. During a lunch meal, dietary staff handled chicken fried steak with gloved hands while cutting it, then touched a resident’s shoulder and continued plating and cutting food for multiple residents without changing gloves or performing hand hygiene, contrary to proper infection control practices acknowledged by the FSM.
Surveyors found that kitchen staff did not follow required food safety standards for storage, labeling, and dating of food items. In the walk-in freezer, an open box of frozen French bread dough and an open bag of frozen chicken breast were not sealed or dated, and a loaf of sliced bread was found on the floor between the wall and shelving. In the walk-in refrigerator, a container of heavy cream was stored past its best-by date. These practices did not comply with FDA Food Code requirements or the facility’s food safety policy for inspecting, properly storing, labeling, dating, and covering food items.
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