Kitchen staff failed to keep major equipment clean, with the stove, deep fryer, and two ovens observed with heavy grease and food residue and no cleaning schedule for the ovens or deep fryer. Staff also did not consistently wear proper hair or beard restraints, as a male cook with a beard and a female staff member with exposed hair were observed without adequate coverage. Dietary staff also incorrectly calibrated thermometers and handled food with poor hygiene practices while plating and temping meals.
Failure to Date, Label, and Cover Stored Food: Food items in the kitchen were found stored without required dates, labels, or proper covering. An open package of bread in the refrigerator had no date, and multiple frozen items, including waffles, pork ribs, sausage links, and pork chops, were opened and/or exposed without labels or dates. The DS confirmed the findings and stated there was no schedule for checking food dates or expired items.
Failure to Check Hot Food Temps During Meal Service: A DA placed new batches of fried chicken and macaroni and cheese on the tray line and plated them without checking temperatures, despite a facility policy requiring hot and cold food temps to be taken before each meal service. The ADD questioned the DA, who admitted the chicken temp had not been taken, and the Administrator stated that any additional food prepared must also have its temp checked.
A microwave in a 200-hall nourishment room had burn spots, chipped and peeling paint, exposed metal, and rust. Staff stated it was used for popcorn and residents’ personal food, but the RN and DM did not know the cleaning schedule or who cleaned it, and the Administrator said it would need to be replaced.
Out-of-range nourishment refrigerator temperatures were observed in the North Unit Hall-100 nourishment room. The refrigerator held resident supplements, juices, and personal food items, and the temperature gauge read 46 degrees F, above the facility’s required 41 degrees F limit. Records showed repeated elevated readings over several days, and interviews with the KM, Maintenance Director, and Administrator confirmed the issue had been reported and that the refrigerator and thermometer had been replaced or changed, but temperatures remained out of range.
Unclean kitchen equipment and storage areas were observed in the dietary department. A large manual can opener had dried, sticky residue on the blade and base, the oven and stove top spill pan had dried and burned food buildup, and four drawers storing serving utensils and adaptive eating items had dried substances and loose food debris. The DM confirmed the items were unclean and stated the drawers, oven, and spill pan should be cleaned weekly or as needed, while the can opener should be cleaned after each use.
Surveyors found that nourishment room refrigerators on multiple units were not maintained within the facility’s required temperature range and that temperature logs were frequently incomplete or missing. In several units, recorded refrigerator temperatures were consistently above 40°F, and multiple days had no temperature documentation at all. One refrigerator lacked an internal thermometer. During interviews, leadership reported that kitchen staff are responsible for checking nourishment rooms, a supervisor aide reviews for expired items and logs, and the staff member currently assigned to these checks is new, while the Administrator stated that kitchen and nursing staff are expected to monitor temperatures and stocking with training provided during orientation and annually.
Surveyors found that dietary staff did not consistently label or discard expired food items, including unlabeled shredded cheese, sundried tomatoes, carrots, coleslaw mix, spinach, and croutons. These items were not stored according to facility policy, which requires proper labeling, dating, and stock rotation. The CDM and Administrator confirmed that staff are responsible for these tasks and that expectations were not met.
Staff failed to perform hand hygiene before handling clean dishes in multiple kitchens, and kitchenware was stored while still wet, contrary to facility policy. These deficiencies had the potential to affect nearly all residents receiving dietary services.
The facility did not obtain food from approved sources and failed to follow professional standards for storing, preparing, distributing, and serving food.
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