Surveyors found that ice machines on two nursing stations were visibly soiled, with stained and discolored plastic components and, in one case, a brown fuzzy buildup on the evaporator grid and surrounding surfaces. Staff, including a NA and an LPN, confirmed the machines were used to obtain ice for residents and acknowledged the parts were not clean, while also indicating they did not know cleaning frequencies or responsibilities. A maintenance worker reported cleaning one of six ice machines per month, and the ADM confirmed the unclean conditions and the absence of a defined process to keep the ice machines clean and sanitary.
Food service sanitation and hand hygiene deficiencies were identified when the ice machine and convection oven had visible soil, the ice machine cleaning schedule in policy was not followed, and the dishwasher wash tank did not reach the required hot water sanitizing temperature. Staff were also observed changing gloves without hand hygiene and handling food and equipment in ways that did not maintain proper sanitation; the DM confirmed the observed conditions and practices.
Kitchen ventilation covers and walk-in cooler circulation fans were observed with visible dust-like buildup. Four ceiling vent covers over food prep areas had grey fuzzy specks, and two cooler fans had a heavy black fuzzy coating while blowing toward food on shelves. The DM confirmed the buildup and stated dust could fall into the food, and the DON confirmed all residents ate food prepared in the kitchen.
Surveyors found that hot lunch items, specifically BBQ pork, were held on a second-floor steam table at temperatures below required standards, with documented readings as low as 119–125°F despite facility procedures and FDA Food Code requirements that hot foods be held at or above 135°F and reheated to 165°F if they fall below that threshold. The Food Service Director acknowledged that cold BBQ sauce had been added to cooked pork and that the initial steam table temperature should have been 165°F, yet temperature logs and on-site measurements during the meal service showed the food remained below the required hot-holding temperature for residents on the unit.
Expired and improperly dated food items were found in the storage room, including condensed milk, Splenda, poppy seeds, graham cracker pie crusts, cake sprinkles, vanilla pudding, cheesecake mix, and ranch dressing mix. Several opened dry goods were marked only with a month and date and no year, and the Dietary Mgr confirmed the expired items and undated packages should be discarded.
Surveyors found unlabeled and undated foods in the kitchen and walk-in refrigerator, along with soiled storage containers, drawers, and a food scale with residue. A cook was observed preparing multiple menu items without hand hygiene, using bare hands on frozen foods, handling foods and sauces without temperature checks, and retrieving rice from the dirty pan area. During meal service, staff served residents with the same gloved hands after touching doors, resident items, and other potentially contaminated surfaces, and the DM confirmed gloves do not replace HH.
Food Storage, Cross-Contamination, and Expired Food Handling Deficiencies: The facility had repeated freezer temperatures above 0°F across multiple freezers, with logs that did not identify which freezer each record belonged to. During kitchen observation, a cook handled raw hamburger patties and then continued food prep with the same gloves while touching rolls, packaging, utensils, and buns before removing gloves and performing hand hygiene. Surveyors also found expired juices and other foods that were undated, liquefied, or otherwise no longer suitable for consumption.
Surveyors found that dietary staff did not follow facility policies for personal hygiene and handwashing. A dietary aide with a full beard worked in the kitchen and handled dishes without a beard cover, and another aide wore a hair cap that left loose hair exposed while working around exposed food and serving drinks. The facility’s policy required full hair and beard restraints. Additionally, a cook repeatedly washed hands for only 4–10 seconds with soap and water instead of the policy-required 20 seconds while engaged in meal preparation and related tasks, potentially affecting all residents receiving food.
Food storage, staff hygiene, and kitchen sanitation deficiencies were observed in the dietary department. Raw chicken was thawing in the same pan as a precooked chicken product, unwrapped hot dogs were found in an unclean food prep sink, a dietary staff member was not wearing a beard restraint while preparing and serving food, and multiple cooking equipment surfaces were heavily soiled with dried-on food spills; the DON confirmed the equipment cleaning schedule was not in place.
Food Safety Deficiencies in Egg Preparation and Sanitizer Monitoring: The facility failed to use pasteurized eggs for soft-cooked eggs and failed to have test strips available to verify quat sanitizer concentration at the 3-compartment sink. During observation, whole eggs in the walk-in refrigerator were not documented as pasteurized, and the DDD and RD confirmed the wrong eggs had been ordered even though facility policy requires pasteurized eggs for soft eggs. The DDD also could not locate sanitizer test strips, and the sink sanitizer log was incomplete and not current.
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