Improper Cold Food Temperature Monitoring
Summary
The facility failed to ensure that food was served in accordance with professional standards for food service safety, specifically in the Madison dining room. During a lunch meal observation, the temperature of two yogurt containers was measured at 60 and 62 degrees Fahrenheit, which is above the normal range of below 41 degrees Fahrenheit. The facility's policy on food safety clearly states that potentially hazardous foods, such as yogurt, must be maintained at or below 41 degrees Fahrenheit to prevent the rapid growth of pathogenic microorganisms that can cause foodborne illnesses. The Dietary Supervisor, upon measuring the yogurt temperatures, acknowledged the increased risk for infection and gastrointestinal issues if food is served outside the proper temperature range. The Food Service Director confirmed that the temperature of cold food items is checked when placed on resident trays and stored in a walk-in refrigerator until service. However, the trays were delivered to the dining room approximately 22 to 27 minutes before the temperature was checked, leading to the yogurt being served at an unsafe temperature. The Administrator was unaware of the issue until notified during the survey process.
Plan Of Correction
Plan of Correction: Approved January 28, 2025 Plan of Correction F812 SS:D I. Immediate Action a. All residents' trays in the (NAME) dining room receiving yogurts on 12/30/24 was immediately removed from the trays and replaced with new items from the kitchen transported to the dining room on ice by the Food Service Director. All residents receiving yogurt at meals have the potential to be affected by this practice. No residents were affected. b. The Dietary Supervisor received 1:1 education on 1/16/25 by the Assistant Director of Nursing with the Food Service Director present on transporting all yogurt and milk on ice to the assigned serving area and adding items to tray at the time the tray is being served to the resident to ensure the items are served within the safe temperature. Any items identified outside the safe temperature zone must be immediately discarded. All items requiring refrigeration must be refrigerated. c. The Food Service Director was in serviced on 1/16/25 by the RN (ADNS) on transporting all yogurt and milk on ice to the assigned serving area and adding items to tray at the time the tray is being served to the resident to ensure the items are served to the resident within the safe temperature. All food items requiring refrigeration must be refrigerated and any items identified outside of the safe temperature zone must be immediately discarded. II. Identification of Others a. All residents receiving yogurt at meal services have the potential to be affected by this deficient practice. No residents were affected. b. An audit was conducted on 1/16/25 by the Food Service Director including temperature check of all yogurts for resident in house receiving yogurt at meals with no negative findings. III. System Changes a. The Policy and Procedure Titled Food Safety/Storage/Distribution/Service Procurement General dated 6/2024 was reviewed on 1/16/25 by the Medical Director, Food Service Director and the Administrator with no changes made. b. All Dietary employees will be re-in-service on the Facility’s Policy Titled Food Safety/Storage/Distribution/Service/Procurement by the Food Service Director and the Educator/Designee. IV. Quality Assurance a. An audit tool was created by the Administrator to conduct random temperature checks for all residents receiving yogurt and milk at random meals to identify any unsafe temperature to ensure items are stored and served at a safe temperature. b. Audits will be completed by the Food Service Director daily x 30 days then bi-weekly x 4, then monthly x 2 months and quarterly x 3 quarters until 100% compliance is achieved. c. All negative findings will be brought to the attention of the Administrator immediately and addressed by the Food Service Director/Designee immediately. d. All results of the audits will be brought to the QAPI committee quarterly x 4 to review and discuss any unfavorable trend that may prevent achieving 100% compliance. V. Person Responsible Administrator. VI. Completion date: 2/25/25
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
Dirty can opener and contaminated dry storage bins: The DCS observed four labeled dry-goods bins with dirty rims, dry matter on the bin walls, and a scoop left inside a flour bin with flour on it. The attached can opener also had dry red matter on the blade, and the cook said it had been used that morning to open cream of corn for lunch. The DCS verified the findings and stated the can opener should be washed after each use and the dry bins and scoops should be kept clean.
Kitchen staff failed to properly date-mark, store, and discard food items, with multiple opened or undated foods found in a walk-in refrigerator past the facility’s 7-day limit or otherwise not labeled. Surveyors also observed wet stacked pans, uncovered utensils with crumbs, and staff personal items such as a cell phone, keys, snacks, and drinks in food prep and storage areas. The MNFS-C stated foods should be dated when opened and discarded after 7 days, and acknowledged concerns about contamination.
Wet steam table pans were found stacked before fully air drying, with water dripping from two pans onto the pans below. The DM stated the pans should have been completely dry before storage and that staff may have been in a hurry. The administrator stated dishes were expected to be dry before storage, and the facility policy and FDA Food Code required dishes and prep equipment to drain and air dry before being stacked or stored.
Expired buttermilk and undated pre-made salads were found in the prep-area refrigerator, while thawing meats in the walk-in cooler were stored together on the same tray in blood juices and one sleeve of ground beef had a hole with exposed dried meat. The walk-in freezer was overcrowded with boxes blocking the walkway, open seafood was left unsecured, thawed chicken was placed on a plastic cover on the floor, and the cooler floor had spilled juices, debris, and a dirty cup. The cook and C-B confirmed the storage and thawing problems, and the admin acknowledged ongoing concerns with expired items and kitchen cleaning.
Surveyors found that the facility did not maintain sanitary conditions in the walk-in freezer and ice machine area. Ice buildup on freezer lines was encroaching on a box of burritos, and an ice scoop holder attached to the ice machine contained standing water with two scoops resting in it and no visible drainage. The Dietary Manager acknowledged the recurring ice buildup and reported that the standing water issue had not previously been raised. These practices did not follow the facility’s policies for food safety, storage, and ice machine preventative maintenance and had the potential to affect 46 residents who consumed food from the kitchen.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Dirty can opener and contaminated dry storage bins
Penalty
Summary
The facility failed to keep 1 of 1 commercial can opener clean and sanitary and failed to store dry goods removed from original packaging in a manner that reduced the risk of cross-contamination. During an initial tour with the Director of Culinary Services (DCS), four white plastic bins in the food preparation area were observed on the floor and labeled for flour, white sugar, rice, and powdered sugar. The flour bin was about one-third full and had a black scoop partially covered with flour, including the handle. The bin labeled white sugar had yellowish-tan dry matter on the right lateral wall, and the front wall had red dry matter measuring 6-7 cm in diameter. The rims around the lids of all four bins were dirty with dark dust-like particles, and the DCS verified these findings and stated the scoop should not be left inside the bins and needed to be clean inside and out. The attached [NAME] brand can opener was also observed with its blade halfway covered with dry, red-colored matter. On a later kitchen tour, the can opener blade still had dry red matter, which had been pushed upward by 0.2 cm, and a small light amber particle was noted below it. The cook stated he had used the can opener that morning to open a can of cream of corn used for lunch. The DCS verified the dry matter on the can opener and stated it should be washed every time it was used to prevent cross contamination. Facility policy stated dry storage areas would be maintained to keep food safe and free of infestation or contamination, and the sample cleaning schedule stated can openers should be clean after each use.
Kitchen Food Storage and Sanitation Deficiencies
Penalty
Summary
Food stored in the kitchen refrigerators was not labeled, dated, or discarded in accordance with facility policy and professional standards. During the kitchen tour, surveyors observed opened foods in a walk-in refrigerator that were past the facility’s seven-day window or were undated, including facility-made strawberry frost dated 3/19, chopped red onion dated 4/25, red grapes dated 10/14 with a cloudy whitish/grayish liquid in the bag, Chef Grade hard boiled peeled eggs dated 4/21, lettuce with no date and brown leaves, and an undated sour cream container that was about half full. A sign on the refrigerator stated that all dated food items must be tossed at the end of 7 days. The MNFS-C removed the items and stated foods were to be dated when opened and prepared foods were to be discarded after seven days. The MNFS-C also stated staff date-mark foods when opened with the month and day and do not include the year. Additional kitchen observations showed two stacked stainless steel pans with water on the inner surfaces, three containers of utensils left uncovered on a wire cart with crumbs in one container, and personal items belonging to staff on or in food preparation counters and storage areas, including a cell phone, car keys, a pink mini wallet, a small bag of chips, plastic water bottles, and a thermal mug. A cell phone was also observed in a drawer with utensils. The MNFS-C stated the pans should have been completely dry before stacking and was unaware utensils should be in a drawer or covered container. The FSA-A stated personal items such as cell phones, keys, and snacks were not appropriate in food prep areas and could lead to distractions. The RD-F stated monthly audits had identified staff not dating opened food, and the administrator stated she expected the MNFS-C to oversee the kitchen and ensure staff adhered to policies and regulations.
Wet Steam Table Pans Stored Before Drying
Penalty
Summary
The facility failed to store steam table pans in a sanitary manner. During observation on 5/12/26 at 10:34 a.m., a stack of five 10-inch by 12-inch steam table pans was seen, and when the pans were separated, two of them had water dripping from them onto the pans below. The dietary manager stated that after washing, the pans were supposed to completely air dry and should not have been stored wet, and that staff may have been in a hurry and not allowed the pans to fully air dry. The administrator later stated that all dishes in the kitchen were expected to be completely dry before storage, and that storing dishes while still wet could allow germs and bacteria to grow and then be passed on to residents. The facility policy stated dishes and food prep equipment were not to be towel dried and were to be stored in a clean, dry area after drying, and the FDA Food Code stated dishes and prep equipment must be allowed to drain and air dry before being stacked or stored.
Expired Foods, Unsafe Thawing, and Unsanitary Kitchen Storage
Penalty
Summary
The facility failed to ensure food was not outdated, that foods were thawed in a safe and sanitary manner, and that the walk-in freezer and walk-in cooler floors were kept sanitary in the kitchen. During observation and interview, a 1/2 gallon container of buttermilk was found in the refrigerator next to the prep area with the lid off, with pancake-batter-like residue on the outside and inside of the container, and the best used-by date was 4/6/26. In the same refrigerator, five bowls of undated pre-made salad were covered with plastic wrap and the lettuce was starting to turn brown. The dietary cook confirmed the buttermilk was expired and the salads should have been dated. In the walk-in cooler, two sheet pans were observed on the bottom shelf of a wire rack with thawing meat items sitting in juice on the trays. One tray held a bag of turkey thawing with juice on the tray, and another tray held two wrapped items and a 10-pound sleeve of ground beef sitting in blood juice from one of the items. The ground beef sleeve had a hole in the plastic with dark, hard-looking exposed ground beef. A later observation identified another wrapped item labeled ham dated 5/5/26 on the bottom shelf. The dietary cook and later the cook confirmed the meat should have been on separate trays and that the items were sitting in blood juices on the same tray. The walk-in freezer inside the cooler was observed to be full of stacked boxes in the walk-through space, with some boxes tipped over, some on the floor, and some on a plastic crate, preventing entry into the freezer. One box labeled seafood was open and dated 3/27/26, with the bag inside not closed or secured. A plastic tote cover on the freezer floor held five bags of thawed chicken, which the cook stated had just been placed there because there was no room on the shelf. The walk-in cooler floor also had a large amount of blood or brown juices spilled under both wire racks, along with butter packets and a dirty plastic cup in the spilled material. The administrator stated there had been ongoing concerns with expired items and cleaning in the kitchen, and the dietician stated the kitchen needed better monitoring and cleaning protocols with audits.
Unsanitary Walk-In Freezer and Ice Scoop Storage Practices
Penalty
Summary
Surveyors observed that the facility failed to maintain sanitary conditions in food storage and ice handling areas. During an initial kitchen tour, the walk-in freezer was found to have ice buildup on the freezer lines that extended far enough to encroach on the upper stacked box of burritos. The Dietary Manager acknowledged during interview that this ice buildup had occurred before. At the end of the tour, inspection of the ice machine revealed an ice scoop holder mounted on the side of the machine containing two ice scoops, with approximately 20 milliliters of standing water in the bottom of the holder and the scoops in direct contact with the water, and no visible way for the water to drain. The Dietary Manager stated that no one had ever mentioned the standing water in the scoop holder before. These conditions were inconsistent with the facility’s written policies on food safety and storage and on ice machine preventative maintenance, which require that food and supplies be stored and handled to ensure safety and sanitation and that exterior surfaces, including the catch basin, be wiped down with a clean cloth and food-safe sanitizer. The deficiency had the potential to affect 46 residents who consumed food from the kitchen.
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