Failure to Maintain Hand Hygiene During Meal Prep: During lunch service, a cook dropped a butter container lid on the floor, picked it up, and continued plating food without hand hygiene. She also coughed into her hand while holding a resident plate, drank from her personal cup placed on a food transport cart, and kept preparing resident meals without washing or sanitizing her hands. The ADM and DM gave conflicting views on the beverage placement, but the DM stated the cart top was not a designated space for staff drinks.
A dietary aide failed to follow hand hygiene and food safety practices during meal service in the Central dining room. She touched her face, hair, pants, and a resident, then handled and served resident food without washing or sanitizing her hands, used bare hands to apply butter to a resident’s bread, washed her hands for only about 4 seconds, and put a milk lid back on a container after it fell on the floor. The DM confirmed the expected hand hygiene and food handling practices, and the facility policy required handwashing for at least 20 seconds before and after handling food and resident contact.
Surveyors identified multiple food safety and sanitation failures, including staff using the same disposable gloves to handle surfaces and then directly touch RTE food and dishware, and a dietary aide preparing deli sandwiches for staff and residents without changing gloves or performing hand hygiene after leaving and re-entering the kitchen. Thermometer probes were stored in sanitizer containing food debris and were wiped on a cloth instead of being sanitized with alcohol wipes before checking food temperatures. The kitchen and walk-in cooler had heavy dust on vents, fans, ceilings, and light fixtures, and the commercial dishwasher had significant food scum and limescale buildup, with many missed deliming sessions and numerous undocumented dish machine temperatures despite policy requirements. Potentially hazardous foods were left at room temperature for extended periods, raw bacon was stored above RTE mashed potatoes, frozen beef patties were left uncovered in the freezer, and multiple expired or visibly spoiled items, including flavor extracts, food coloring, coffee syrups, relish, and dressing with apparent mold, were found in storage without appropriate dating or rotation.
Surveyors found that kitchen staff did not follow proper hand hygiene procedures, specifically failing to use a paper towel to turn off the faucet after washing hands, as required by facility policy. The kitchen and food storage areas were not maintained in a clean condition, with dust and buildup observed on equipment and surfaces. Additionally, food items in the dining room refrigerator were improperly labeled and stored, with some items undated, spoiled, or moldy, and not discarded as required by policy.
The facility did not consistently monitor or document the low-temperature dishwasher's wash temperatures, resulting in multiple instances where the required minimum of 120°F was not met and numerous undocumented temperature checks. Staff, including the dietary supervisor and maintenance technician, were unaware of the ongoing issue, and the facility's policy for dishwasher sanitation was not followed.
Staff did not consistently perform hand hygiene or use gloves properly while handling and serving food, including touching hair, face, and uniforms before serving meals, and failing to wear required hairnets. Food items were left uncovered and accessible, with residents touching food that was later served to others, in violation of facility policies.
Kitchen equipment surfaces and food storage areas were found to be unclean, with buildup of dirt and unidentified substances on the dishwasher and freezer, and improper storage of food items. Staff interviews and cleaning schedules revealed that required cleaning tasks were not consistently completed or documented, contrary to facility policy.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
Surveyors found that staff did not consistently document completion of kitchen cleaning tasks or coffee temperature checks, and a dietary aide failed to perform required hand hygiene before and after handling food and serving meals. These actions were not in accordance with the facility's policies for sanitation and infection prevention.
Staff did not consistently document food temperatures for 40 out of 192 meals, resulting in a lack of evidence that meals were heated to safe temperatures before serving. The dietary manager and interim administrator confirmed that kitchen staff were responsible for this documentation, and that missing records meant there was no proof food safety standards were met.
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