Improper Food Storage, Labeling, and Temperature Control in Dietary and Therapy Areas
Summary
Surveyors identified a deficiency related to food safety and storage practices in the facility’s dietary and ancillary food storage areas, affecting all 69 residents who received food from the kitchen. During observations, an unsealed, open-to-air bag of dried onion flakes was found, and the Dietary Manager (DM) confirmed it was not properly sealed and should have been discarded. In stand-up freezer #1, surveyors observed an undated, open bag of flour tortillas and an undated, unlabeled milkshake, which the DM acknowledged were not dated, not properly sealed, and should have been discarded. In a kitchenette refrigerator next to the main kitchen, surveyors found visibly spoiled lettuce, a package of cheese, and a box of hamburgers, all unlabeled and undated; the DM confirmed these items should have been discarded. In stand-up refrigerator #1, a bag of turkey lunchmeat and a bag of ham lunchmeat were found unsealed and open to air, and the DM again confirmed they were not properly sealed and should have been discarded. Further observations showed additional food safety issues. Stand-up freezer #2 contained two thermometers reading 48°F while storing individually packaged orange, prune, and apple juices labeled to be kept below 38°F, along with boxes of individually wrapped dinner rolls and doughnuts; the DM confirmed the elevated temperature and that the juices’ storage instructions required temperatures below 38°F. The Administrator later confirmed awareness that the freezer was under consideration for repair or replacement but was unaware that food and beverages were being stored in it. In stand-up refrigerator #4, an unsealed bag of cheese and a bag of thawed frozen strawberries dated as opened on 03/07/26 were found, and the DM confirmed the cheese was not properly sealed and the strawberries had expired. In freezer #3, a bag of chicken fingers was found unsealed and open to air, which the DM stated should have been discarded. In the therapy gym refrigerator and freezer used to store resident food, surveyors found meat and crackers labeled only with a resident name but undated, a premade salad in a takeout container unnamed and undated, a partially consumed milkshake open to air with no name or date, and an opened, unnamed, undated half-gallon container of vanilla ice cream; the Therapy Manager confirmed these items were not properly labeled and dated and should have been discarded.
Plan Of Correction
F 0812 F 0812 No resident experienced negative effects related to the unsealed box of dried onion flakes observed on 03/23/2026 @ 09:21 am. No resident experienced negative effects related to the undated bag of flour tortillas that were open-to-air and undated, observed in stand-up freezer #1 on 03/23/2026 @ 09:23 am. No resident experienced negative effects related to the undated and unlabeled milkshake that was observed in stand-up freezer #1 on 03/23/2026 @ 09:23 am. No resident experienced negative effects related to the unlabeled and undated visibly spoiled lettuce, package of cheese, and box of hamburgers observed in the kitchenette next to the main kitchen refrigerator on 03/23/2026 @ 09:27 am. No resident experienced negative effects related to the unsealed and open-to-air bag of turkey lunchmeat and bag of ham lunchmeat observed in stand-up refrigerator #1 on 03/23/2026 @ 09:39 am. No resident experienced negative effects related to the individually packaged servings of orange juice, prune juice, and apple juice; as well as individually wrapped dinner rolls and doughnuts observed in stand-up freezer #2 which contained two thermometers reading 48 degrees Fahrenheit, on 03/23/2026 @ 09:42 am. No resident experienced negative effects related to the unsealed bag of cheese and gag of thawed frozen strawberries with an open date of 03/07/2026, observed in the stand-up refrigerator #4, on 03/23/2026 @ 09:39 am. No resident experienced negative effects related to the unsealed bag of chicken fingers observed in freezer #3 on 03/23/2026 @ 09:50 am. No resident experienced negative effects related to the labeled [R] [R] meat & crackers which was undated; and a premade salad in a takeout container unnamed and undated, observed in the therapy gym refrigerator on 03/26/2026 @ 12:16 pm. No resident experienced negative effects related to the partially consumed milkshake that was open-to-air with no name of date and a half-gallon container of vanilla ice cream that was opened, unnamed and undated, observed in the therapy gym freezer. LNHA notified Medical Director on 04/06/2026 of the findings noted during Annual Survey that involved inappropriately stored foods/drinks and that no negative effects were identified in any resident related to the inappropriately stored foods/drinks. No new orders were received from Medical Director. LNHA/Designee will educate licensed and unlicensed personnel in the following: §483.60(i)(1)(2) Food Procurement, Store/Prepare/Serve-Sanitary §483.60(i) Food safety requirements. The facility must - §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. LNHA/Designee will complete daily rounds, observing food storage areas, ensuring that all items are labelled, dated, unexpired, and stored appropriately (i.e., appropriate temperature levels in refrigerators (<41 degrees Fahrenheit), freezers (at or below 0 degrees Fahrenheit). Issues will be addressed upon recognition of issue. Also, LNHA/Designee educated Dietary Manager & Therapy Director on 03/26/2026 that staff foods/drinks must be stored in separate refrigerators/freezers than residents. Further, all items in the resident's refrigerators/freezers must be dated/labeled and expiration date(s) observed. Any expired, unlabeled, or undated items are to be discarded straight away. Dietary Manager also educated on 03/26/2026 that refrigerators storing food and beverages must meet the temperature threshold of <41 degrees Fahrenheit (refrigerator) or 0 degrees or less (freezer). Freezer that was being utilized as a refrigerator was removed from service on 03/26/2026. Juices were moved to an actual storage refrigerator, within acceptable temperature range. There is adequate storage space for refrigerated and frozen items, so replacement of malfunctioning freezer is not necessary, but on or before 04/30/2026, the interdisciplinary team (IDT) will meet and discuss benefits of purchasing a new refrigerator/freezer and determine necessity. If necessary, quotes will be obtained by LNHA and purchase made. Dietary Staff will observe & record refrigerator and freezer temperatures every shift, at least twice daily to ensure temperatures are within acceptable limits (refrigerator < 41 degrees Fahrenheit and freezer at or below 0 degrees Fahrenheit). Any failing equipment will be removed from service immediately and reported to Maintenance for corrective action. Dietary Manager will be responsible for ensuring this occurs. Compliance will be determined by daily review of Dietary staff documentation by Dietary Manager. Dietary Manager audited refrigerators located in the kitchen, kitchenette, and Therapy gym on 03/26/2026. Undated, unlabeled, and expired items were discarded. Dietary Manager also verified that all refrigerators and freezers in use in the kitchen, kitchenette, and Therapy gym were within appropriate temperature range(s) (< 41 degrees refrigerator & at or below 0 freezer) on 03/26/2026. LNHA/Designee will complete audits that determine if foods & drinks are being appropriately stored and that Dietary staff are consistently and appropriately monitoring refrigerator and freezer temperatures (below 41 degrees Fahrenheit). Inappropriately stored items will be addressed straight away. These audits will be completed on at least 3 refrigerators/freezers every week x4; then as determined by QAA.
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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