Surveyors determined that the main kitchen’s low-temp dishwasher was not maintaining proper sanitizer levels when test strips repeatedly showed 0 PPM, even though the Dietary Manager reported that the chemical solution was checked each shift and should read 100 PPM. On the same day, staff had documented a 100 PPM sanitizer level and appropriate rinse temperature on the dish machine log, which conflicted with the observed test results. Facility policy required recording sanitizer levels between 50–100 PPM on the log multiple times per day. This issue had the potential to affect all residents receiving meals from the kitchen.
Surveyors found that dietary staff failed to follow food safety and sanitation standards, including improper use of beard restraints while working over food, inadequate hot-holding temperatures for items such as baked chicken, mashed potatoes, and vegetables, and visibly soiled hall tray carts with heavy brown debris on rails and wheels. Several cognitively intact residents reported poor food quality, including cold or lukewarm meals, dry and overcooked items, and rubbery eggs, particularly for trays delivered to rooms. Grievance records documented repeated complaints about cold and poor-quality food, while facility policies required proper hair restraints, correct cooking and holding temperatures, and regular cleaning and sanitizing of carts and equipment.
Surveyors found that resident-use refrigerators on two nursing units contained improperly stored and unlabeled food items, as well as staff personal food and other items. On one unit, an LPN reported that a nurses' station refrigerator was used for residents, yet it held outdated and undated food, open beverage containers, and uncovered frozen items inconsistent with the facility’s Food Storage policy. On another unit, a dining/kitchen refrigerator and freezer contained a staff lunch tote, a candy bar, a bag of flour, and ice packs used on a resident’s breast for cancer-related care. The Regional Director of Operation confirmed that staff were not supposed to store personal food in these refrigerators and that a separate break room was available for staff food storage.
Surveyors observed a cook handling ready-to-eat food with bare hands during a lunch meal service, including picking up rolls by hand to place on plates and using a bare hand to retrieve a portion of mashed potatoes that had fallen onto a pan handle and returning it to the main pan. In subsequent interviews, the cook acknowledged possibly touching bread with bare hands, while the Dietary Manager and DON confirmed staff are not permitted to touch food with bare hands. Review of the facility’s Safe Food Preparation and Handling policy showed it requires strict personal hygiene and prohibits direct bare-hand contact with ready-to-eat foods.
Improper egg pasteurization and unsafe cold food storage. During kitchen observations, the walk-in cooler door was propped open, the floor was wet, and the cooler temperature read 55 degrees F with no second thermometer available. A box of eggs in the cooler had no visible P stamp or label showing they were pasteurized, and an old pizza was also found stored in the cooler. The Dietary Mgr stated eggs were sometimes cooked to order, including eggs with yolks not completely cooked, and later said eggs could be purchased from the store if needed.
Food was found stored improperly in the kitchen, including sliced and shredded cheese left open to air, a coleslaw carton past its use-by date, and bulk sugar and oatmeal containers left open to air. The low-temp dish machine sanitization log was blank even though the DM stated staff were supposed to record sanitizer levels before each meal.
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
Unsanitary kitchen conditions were observed across multiple kitchen checks, including brown water with egg particles on a dish room table, sticky film on coffee decanters, dried spills on the floor, heavy crust on stovetop burners, debris under dry storage shelving, and breadcrumbs on a prep table and floor. A walk-in freezer had a leaking condenser pipe wrapped in foam tube and tape, and a bucket had been used to catch water; a Robot Coupe used for pureeing food had a cracked lid and remained in use until replacement. The Dietary Mgr and Maintenance Dir described ongoing issues with the freezer pipe, and the facility policy required the food service area and equipment to be kept clean and in good repair.
Surveyors found that the facility used non-pasteurized shell eggs to prepare over-easy eggs for three residents each morning for about a month, while other residents received liquid eggs. Kitchen staff were unsure whether the eggs were pasteurized, and the supplier later confirmed they were not. On two observations of the dry storage area, scoops for bulk flour and sugar were left uncovered on top of the containers, and the dietary manager and DON acknowledged there was no specific policy for handling these scoops, despite an existing food procurement policy addressing egg purchasing specifications.
Dirty pans and dishes were stored on a grill, food and supply boxes were kept on the floor in the freezer, dry storage area, and hallway, and the grill had crumbs and debris on it. A Sous Chef also checked food temps using thermometers that were not sanitized between foods, wiping them on the same towel instead of using probe wipes as required by policy.
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