Deficiencies in Food Service Safety and Cleanliness
Summary
The facility failed to ensure that food was stored, prepared, distributed, or served following professional standards for food service safety in both the main kitchen and resident unit nutrition areas. During the initial inspection, surveyors observed a build-up of debris on the manual can opener and mixer, dust and dirt on fire extinguishers, and a large pool of free-standing water on the floor of the walk-in refrigerator. Additionally, the storage area for clean pots, pans, and food containers had items that were not fully dried, and the rolling toaster had a significant amount of debris underneath. The final rinse pressure on the dishwasher was below the recommended level due to a malfunctioning gauge. In the East nutrition area, temperature logs for the refrigerator and freezer were missing for several dates, and there was a noticeable accumulation of dirt, grime, and food particles on various surfaces, including the refrigerator/freezer unit, microwave, and drawers. Interviews with the Director of Food Services and the Environmental Services Director revealed that staff were not diligent in cleaning and maintaining the equipment and kitchen areas. The Environmental Services Director acknowledged the lack of cleanliness and mentioned the development of a duty list to ensure daily responsibilities are completed.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 Corrective Action for those identified: Manual can opener was found to have build-up of debris in the cutting area of the device. Mixer had dirt and debris on and under the device. Dust and dirt were on top of two fire extinguishers in the main kitchen. All three of these items were addressed immediately and cleaned during/after the initial walk through. Staff were reminded during a daily kitchen huddle on (MONTH) 6th that the areas need to be cleaned daily. East Nutrition Area: Temperature logs for the refrigerator/freezer in the East Nutrition area were missing dates from (MONTH) 6, 8, 9, 10, and 12, 2025. Dirt and grime was found on top of refrigerator/freezer unit. Dirt, grime, and food particles were found on the freezer bottom and shelves. Dirt, grime, and food particles were found on the refrigerator bottom and shelves. There was dirt and grime on the seals of the refrigerator and freezer. There was dirt, grime, and food particles within the microwave. There was dirt, grime, and food particles built up on the drawers under the microwave. The above listed items were addressed with the staff members responsible for the area at a daily staff huddle on (MONTH) 6th, 2025. Staff were reminded that they are responsible for the cleaning of the refrigerator/freezer, as well as the microwave and drawers underneath. Staff were also reminded that the refrigerator/freezer temps need to be taken and recorded daily. The refrigerator/freezer unit, microwave, and drawers under the microwave were properly cleaned on Friday (MONTH) 28th. West Nutrition Area: Temperature logs for the refrigerator and freezer were found to be missing dates for (MONTH) 9, 10, and 12, 2025. Dirt and grime was found on top of refrigerator/freezer unit. Dirt, grime, and food particles were found on the freezer bottom and shelves. Dirt, grime, and food particles were found on the refrigerator bottom and shelves. There was dirt and grime on the seals of the refrigerator and freezer. There was dirt, grime, and food particles within the microwave. There was dirt, grime, and food particles built up on the drawers under the microwave. The above listed items were addressed with the staff members responsible for the area at a daily staff huddle on (MONTH) 6th, 2025. Staff were reminded that they are responsible for the cleaning of the refrigerator/freezer, as well as the microwave and drawers underneath. Staff were also reminded that the refrigerator/freezer temps need to be taken and recorded daily. The refrigerator/freezer unit, microwave, and drawers under the microwave were properly cleaned on Friday (MONTH) 28th. Walk-in freezer was found to have a large puddle of free-standing water on the floor. Eastern Refrigeration was called to come address the puddle. A small water leak was found around the walk-in cooler and fixed. The storage area for clean pots, pans, and food containers had multiple containers stacked together that were not fully dried. Containers, pots, and trays were put away wet and contained moisture. Shortly after inspection, all pots and pans were pulled and inspected to ensure there was no wet nesting. The staff members responsible for cleaning and putting away dishes were reminded that all pots, pans, and containers need to be fully dried and contain no moisture before they are put away. The rolling toaster contained a large amount of debris under and behind the apparatus. The rolling toaster was moved and the counter was thoroughly cleaned. The issue was addressed with staff at a daily kitchen staff huddle on (MONTH) 6th, 2025. Responsible staff were reminded that this area needs to be cleaned after each use. Dirt and grime were found on the shelving unit above the grill cooking area. The shelving unit was wiped down and properly cleaned shortly after inspection. Discussion with the cooks took place on (MONTH) 6th, 2025 at daily staff huddle reminding the responsible staff members that the kitchen shelving unit needs to be cleaned each day. Final rinse pressure on the dishwasher was 13psi. The signage on the device had a recommendation of 20psi (+ or - 5psi). At the time of inspection, management was aware that the psi was not correct and a call had been made to Action Service, our repair company. (NAME), the Tech from Action Service, had come out and determined the machine was functioning as it should but there was a problem with the PSI Gauge and sensor. The part was immediately ordered and replaced/fixed on Tuesday (MONTH) 4th. Identification of other residents and corrective action: All above listed items will be audited at a frequency of twice per week. The Nutrition Management team already conducts a monthly food safety/sanitation audit. The audit frequency will change from monthly to twice per week for a period of 3 months or 90 days. Measures and Systemic Changes: Education and In-Servicing will take place with Nutritional Services staff to ensure compliance. Twice a week audits will be tracked and reviewed at monthly QAPI meetings measuring compliance of deficient items. Monitoring: Twice a week audits will be tracked and reviewed at monthly QAPI meetings measuring compliance of deficient items. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation, or continuation of audits will be based on QAPI Committee recommendations. Responsible person/title and date of correction: Joe Clemens, Manager of Nutrition Services, by 3/31/25.
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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