Surveyors found that the facility did not follow its own kitchen cleaning schedule, with damaged and ajar ventilation hood filters over the cook top, heavy grease and food debris on the oven and cook top surfaces, and a broken floor section under a steamer containing standing water and food debris. These unsanitary conditions persisted on re-observation. During meal service, disposable plates and utensils were used on the tray line for multiple units because of a shortage of non-disposable plates and silverware, which the Food Service Director attributed to missing items and back-ordered replacements. A resident reported that it would be preferable to have real silverware and plates during meals.
Unlabeled, expired, and personal food items were found in Unit A and Unit D servery refrigerators, along with soiled refrigerator surfaces and food debris on the floor. Staff interviews confirmed that opened items should be dated, discarded within the required time frame, and kept separate from personal items, and that the servery areas should be clean and sanitary.
Surveyors identified multiple failures in food storage, sanitation, and meal service, including a main kitchen reach-in cooler operating above safe temperatures with improperly cooled eggs and other cold foods, and black residue on cooler door gaskets and a walk-in milk cooler ceiling crease in both the main kitchen and a unit pantry. There was no documented kitchen cleaning schedule, no record of gasket or ceiling cleaning, and staff gave conflicting accounts of who was responsible for cleaning refrigerators and gaskets. During meal service, a food service worker attempted to provide a resident with a tray taken from a cart containing dirty and uneaten trays, without a tray ticket, before acknowledging this should not be done and removing the tray.
Surveyors found multiple food storage and labeling violations, including unlabeled almond milk in a walk-in refrigerator, cooked chicken and vegetables held beyond the facility’s 72-hour limit, and a defrosted container of whole eggs without a defrost date. In a pantry refrigerator, several 4-oz fruit and pudding cups were undated, illegibly dated, or past the facility’s allowed holding time, despite policies requiring all perishable and pantry-refrigerated items to be labeled, dated, and discarded after 72 hours. The Food Service Director and dietary staff confirmed the 72-hour standard and labeling requirements and acknowledged that daily rounds intended to remove outdated or improperly labeled items did not prevent these issues.
The facility failed to follow its own food storage and handling policies, resulting in residents receiving expired or improperly held food and beverages. A resident reported curdled, off‑tasting milk that was past its expiration date. Surveyors observed multiple opened, unlabeled, and undated food items in the main kitchen and unit pantries, along with several clearly expired products, including milk and cooked meats. They also found personal and resident food in unit refrigerators and freezers that was not labeled or dated as required. During meal tray assembly, milk portions were left out and measured at temperatures well above the required 40°F or less, and several residents complained that the milk tasted sour even though the cartons were within date. Staff interviews confirmed that policies required labeling, dating, discarding expired items, and maintaining proper temperatures, but staff could not explain why expired and unlabeled foods remained or why milk was allowed to warm during tray preparation.
Surveyors found that food service operations did not comply with professional food safety standards in the main kitchen and all unit nutrition rooms. Facility-made cold sandwiches were stored in multiple dietary and nutrition refrigerators without required expiration dates, and temperature logs for unit dietary refrigerators were incomplete, with no logs available for resident-owned refrigerators. In the walk-in refrigerator, a large pan of beef stew lacked a cooling log and, when checked about two hours after refrigeration, remained at 105°F instead of meeting the required 70°F cooling benchmark, indicating improper cooling and documentation practices.
Surveyors found that the facility failed to follow professional standards and its own policies for food storage and sanitation. In the kitchen, an active ceiling and A/C leak near the walk‑in refrigerator and freezer created standing water on the floor, while tray catties with food covers and a shelving unit with uncovered condiments and peanut butter were stored directly under the leaking area and tarp. Inspectors observed heavy grease and food debris on the commercial oven range and on the wall behind the stove and two‑bay sink, along with broken and missing wall tiles and peeled plaster. Ceiling pipes above food prep and serving stations were covered with thick dust, and a hand wash sink had a leaking drainpipe, a non‑working paper towel dispenser, and a stack of wet paper towels in the basin. The walk‑in freezer had a damaged door gasket, black debris on the window, significant condensation and ice buildup on the door, and a large ice accumulation inside. Interviews with dietary, maintenance, and administrative staff confirmed these problems had been ongoing for months and that staff were aware of the leaks, structural damage, and cleaning deficiencies.
Unlabeled, undated, and expired foods were found in the kitchen and a unit refrigerator during survey observations. Surveyors saw multiple sandwiches, cooked peas, jello, peaches, quiche, chopped lettuce, tuna salad, egg salad, and an expired salad without proper dating, while the FSD stated staff were responsible for removing expired food and nursing staff were responsible for labeling and dating food stored in the refrigerator.
Food was not stored in accordance with professional standards during the survey. Multiple food items in the snack refrigerator, portable tray rack, and freezer were observed without proper identification, including fruit cups, cottage cheese cups, pudding cups, peanut butter cups, mixed vegetables, and lettuce. A dietary cook was also observed slicing chicken breasts without wearing a beard net, and the Dietary Supervisor stated that food needed to be labeled, dated, and that staff were to wear hair and beard nets if needed.
Unlabeled and outdated food and beverages were found in a nourishment refrigerator, including opened thickened dairy drinks, opened apple juice, and an unopened personal yogurt stored with resident food. Staff stated opened items should be labeled and dated and used within 3 days, and the Administrator stated facility policy required items to be discarded after 72 hours.
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