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.
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.
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.
Staff were observed inserting food thermometers through plastic wrap covering food items on the tray line, rather than removing the wrap as required by USDA guidelines and facility policy. This practice was confirmed by interviews with the dietary manager, DON, and administrator, who all stated that proper procedure is to remove barriers before temping food to prevent cross contamination and choking hazards.
The facility did not consistently document food temperatures or maintain proper sanitizing procedures, including incomplete recording of sanitizer test strips and improper use of cleaning cloths. Staff were observed using cleaning cloths without proper sanitization and were unclear about the correct preparation and identification of sanitizer solutions, leading to noncompliance with professional food safety standards.
Staff did not consistently perform required hand hygiene or change gloves during meal service, including after touching potentially contaminated surfaces such as meal tickets, pens, carts, hair, clothing, and items dropped on the floor. This failure to follow infection control policies was observed among multiple staff members, despite facility guidelines and management expectations.
A dietary aide failed to perform hand hygiene after cleaning tasks and did not wear a finger cot over a bandaged wound while handling food. The aide handled a soiled rag and returned to the food line without washing hands, then touched food items, contrary to facility policy requiring handwashing and protective coverings for wounds.
Food in a nourishment refrigerator was repeatedly stored at temperatures above the recommended maximum of 41°F, as documented on multiple days. Staff interviews revealed confusion about the correct temperature range and inconsistent monitoring practices. The DON confirmed the standard was not to exceed 41°F, but this was not consistently followed.
Surveyors identified that the facility did not consistently date or remove expired food items from kitchen and unit refrigerators, including opened and ready-to-eat foods such as salads, cheese, mayonnaise, and juices. Staff interviews revealed unclear responsibilities and inconsistent practices regarding food storage and removal, resulting in expired and undated items being available for resident consumption.
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