Surveyors found multiple opened nutritional supplement containers in unit nourishment refrigerators that were either undated or stored beyond the manufacturer’s specified use-by timeframe. A one-quart shake in one unit refrigerator lacked an opening date despite a label requiring use within four days of opening, while two dated one-quart shakes and an opened, undated diabetic shake in another unit refrigerator were not managed according to their labeled time limits. The DM reported that nursing staff, not dietary, were responsible for dating and discarding resident nutritional shakes, while dietary staff only checked and restocked kitchen-provided items. A nurse and the Administrator both confirmed that the person opening the shake was responsible for dating it and ensuring it was used or discarded within the manufacturer’s guidelines.
Surveyors found that kitchen equipment and food contact surfaces were not maintained in a clean, sanitary condition. Shelves under two steam tables were covered with dried, sticky food particles, door handles on two reach-in refrigerators and a hot box/warmer had dried food debris, and a three-cylinder pellet plate warmer contained dried food particles in all cylinders. These unsanitary conditions were observed on multiple days despite written cleaning schedules requiring thorough cleaning of the steam tables and pellet warmer, and expectations that staff wipe down steam tables after each meal and clean door handles and the plate warmer daily.
Surveyors found that clean dishware in the dietary department was stacked and stored while still wet, resulting in wet nesting of multiple metal serving pans that were ready for use. The Dietary Manager acknowledged that dishware should be thoroughly dried and stored facing down to prevent wet nesting and that such moisture could allow bacteria to grow, but could not identify which dietary staff member had improperly stored the pans. The Administrator also confirmed that items should not be stored wet due to the potential for bacterial growth.
Surveyors found that one walk-in cooler had multiple dark, sticky spills on the floor, including several 4–5 inch spots under a cart holding tea decanters and a larger pooled area of thick liquid with streaks extending out of the cooler into the kitchen. The Food Services Manager believed the spills were from tea and juice and acknowledged there was no sign-off sheet for daily cleaning, though he expected staff to clean spills when seen. The Assistant Food Services Manager reported she had checked the coolers and floors earlier and had not noticed any spills, and no staff had reported them. The Administrator stated the sticky material likely resulted from breakfast preparations and described the incident as an anomaly.
Surveyors identified multiple failures in food labeling, storage, and sanitation, including dirty water spigots above the cooking range, a scoop stored with its handle in direct contact with rice, and unsealed croissants without open or use-by dates in a walk-in cooler. In three nourishment rooms, open food items such as a half-eaten creme pie with used forks, a reusable container of dressing, a pudding cup, a fast-food sandwich, and a milkshake were found without required open and/or use-by dates. The Dietary Manager reported that all nourishment room food must be labeled with both an open date and a 7-day use-by date and noted that new staff and nursing staff were not consistently labeling items as required.
Surveyors found that the facility failed to properly label and date multiple food items stored in the walk-in freezer, including french fries, chicken breasts, sausages, hush puppies, baguettes, gluten-free bread, and a chocolate cream pie. Some items had been removed from original packaging and placed in resealable bags without any labeling, while others in original packaging lacked open or expiration dates. The Dietary Manager stated all freezer items should be labeled and dated when opened or repackaged, and staff had been educated on these requirements. A cook’s assistant and a cook reported performing weekly freezer audits, but one focused only on expired items and did not check labeling, and audits were not documented. The Administrator reported she was unaware that open food items were not being properly dated, although a prior audit had already identified unlabeled or uncovered items in the freezer.
Surveyors found that kitchen staff failed to discard multiple expired food items stored in a reach-in refrigerator, including opened containers of sauerkraut, canned pears, canned tuna, and canned pork and beans that were kept past their labeled discard dates. A weekend cook reported that all kitchen staff were responsible for checking and discarding expired foods but acknowledged he had not checked the refrigerator and had overlooked the expired items on a prior shift. The Dietary Manager stated that perishable foods were to be discarded after 3 days and that staff should have removed the items on their discard dates, while the Administrator stated she expected kitchen staff to check for and remove expired foods daily.
Surveyors found that food items in the walk-in cooler, including a container of pudding and a pan of turkey sandwiches, were stored without labels or dates. The Dietary Manager reported that these items were not present before the weekend and must have been prepared and stored during that time, but the exact timing could not be determined due to missing labels and dates. She stated that she and the Assistant Dietary Manager monitor for unlabeled items during the week, but no one is assigned this responsibility on weekends, and that staff who place food in the cooler are responsible for labeling and dating it. The Administrator confirmed that there should be no unlabeled or undated food items in the walk-in cooler.
Surveyors found unsanitary conditions and improper food storage in the dietary areas, including a walk-in refrigerator with debris and buildup on the floor and shelving that had not been cleaned for an extended period, as well as a dry storage area containing expired thickened liquids and multiple cases of bottled water stored directly on the floor. The Dietary Manager acknowledged responsibility for stocking food and reported that the expired items were overlooked and the water had been placed on the floor during a prior water line break. The Administrator confirmed that established kitchen cleaning protocols and storage standards, including discarding expired food and keeping water off the floor, were not followed.
Surveyors found that kitchen staff failed to label, date, and properly seal multiple opened food items in the walk-in freezer and refrigerator, including pasta, bread, meat, cheese, and stewed apples, some of which showed frostbite, discoloration, and slimy or mushy appearance. The Dietary Manager acknowledged that open items should be labeled, dated, sealed, and discarded as needed. In addition, walls and ceilings in the dishwashing, steamtable/food line, and food prep areas were observed with black substances and deteriorating sheetrock and plaster around AC vents, and staff confirmed that these high surfaces were not being cleaned and had not been repaired.
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