Failure to Perform Hand Hygiene During Meal Service
Summary
The facility failed to adhere to proper hand hygiene protocols during meal service, affecting two residents directly and potentially impacting all 13 residents on the skilled unit. On the specified date, a Certified Nursing Assistant (CNA) was observed serving lunch trays to residents in the dining room without washing or sanitizing his hands between handling the trays and assisting residents with their meals. This included actions such as removing lids and cutting up meat for the residents. The CNA acknowledged during an interview that he did not perform hand hygiene during the meal service, which was contrary to the facility's Infection Prevention and Control policy. Another CNA was observed retrieving and serving lunch trays to residents in their rooms without performing hand hygiene between serving different residents. This CNA also confirmed during an interview that she did not wash or sanitize her hands between serving the trays to two different residents. The facility's policy, dated March 2020, clearly states that all staff must wash their hands between resident contacts and after handling contaminated objects, which was not followed in these instances.
Penalty
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Surveyors found multiple instances of improper food storage and labeling, including undated and unlabeled opened dairy products, beverages, and prepared foods in the main walk-in cooler and freezer, as well as a serving scoop left resting directly on stored pasta. Additional issues included covered but undated pre-poured juices, milk, and thickened beverages in a reach-in cooler used for tray line, and a nurses' station refrigerator containing a dated bag of a resident’s food from over a week prior and three undated half-sandwiches. In a resident’s personal refrigerator, staff confirmed three undated bags of grapes with visible mold. These conditions did not comply with facility policies requiring cold foods to be stored off the floor, wrapped or covered, labeled, dated, and for resident refrigerators to be monitored daily with unsafe or moldy food discarded.
Surveyors found unsanitary kitchen conditions, including a dirty tray holding clean pitchers, soiled storage carts containing clean dishware and disposables, and multiple trays of open juice in a reach-in refrigerator that were unlabeled and undated. In a walk-in refrigerator, they observed a bag of bologna marked only with a freeze date, lacking a thaw or use-by date, and appearing slimy and discolored. Observation of the high-temp dishwasher showed rinse temperatures below the 180°F minimum required for hot water sanitizing, and review of several months of temperature logs revealed repeated sub-minimum wash and rinse temperatures and numerous missing entries. Facility policies required dishwashing to meet specified temperature standards and all refrigerated foods to be covered, labeled, and dated with a use-by date, but these requirements were not consistently followed.
Surveyors found that the kitchen was not maintained in a clean and sanitary condition, with grease and dust on a stove shelf, food buildup inside a microwave, and dried spills on the floor under a refrigerator. The sanitizing solution used to wipe counters and the sanitizer level in a three-compartment sink used for washing and sanitizing equipment and utensils did not meet required levels. These conditions affected all residents receiving food from the kitchen and were confirmed by dietary and administrative staff during the complaint investigation.
Surveyors found multiple unsanitary food storage and preparation practices, including dried food splatters and greasy buildup on cooking equipment, crumb- and spill-covered floors, and a sticky, dusty ice machine filter cover. Undated and unlabeled foods such as pre-filled cereal bowls, fruit desserts, lunch meat, gelatin, red liquid, and coleslaw were observed in various refrigerators, along with expired milk that was discolored and clumped, and an open ketchup bottle with a broken lid that could not be closed. Additional issues included canned tomato juice and a case of hotdogs stored directly on the floor in dry and frozen storage areas. These conditions were confirmed by dietary staff and had the potential to affect all residents receiving meals.
Surveyors found that the facility’s high‑temperature dishwasher was not consistently reaching manufacturer‑required temperatures or completing proper rinse cycles for dish sanitation. Observations showed that during operation, only the wash gauge changed while the pump rinse and final rinse cycles did not engage, and subsequent checks revealed final rinse temperatures below the specified minimum. Review of several months of dish machine logs showed multiple instances of substandard final rinse temperatures, despite facility policies requiring dishwashing to meet temperature and sanitation standards and to follow manufacturer instructions.
Surveyors found that the facility failed to consistently monitor and document food temperatures for multiple meals over two months, despite a policy requiring temperatures of TCS foods to be taken and recorded for each meal. Review of dietary logs showed numerous missing entries for breakfast, lunch, and dinner, and food committee minutes reflected resident reports of undercooked and overcooked items, as well as cold eggs. During an observed lunch service, the Dietary Manager and dietary staff acknowledged that meal temperature logs contained missing temperatures before meals were served, affecting all residents in the facility.
Improper Food Storage and Labeling in Facility and Resident Refrigerators
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards and facility policy, creating the potential for foodborne illness for nearly all residents who received food from the kitchen. In the walk-in cooler, they observed multiple items that were opened and partially used without any open dates, including two cartons of heavy whipping cream, bins of individually poured and covered beverages, and a tray of covered fruit cocktail bowls. A large pan of pasta with ground meat was stored with the serving scoop resting directly on the food, covered with plastic wrap and not dated. A cart in the cooler held a 22-quart container of dark liquid with no label or date, and a pink plastic pitcher resting directly on the cart surface, which was coated with a dark unidentified material. A box of bacon was stored directly on the floor. The Director of Dietary Services confirmed the presence of undated, unlabeled, and improperly stored food items in the walk-in cooler. In the walk-in freezer, surveyors found an unsealed and undated bag of frozen chicken breasts and an unsealed and undated bag of pork pizza topping, which the Director of Dietary Services also confirmed. The reach-in cooler used for tray line contained a variety of pre-poured juices, milk, thickened beverages, and tea that were covered but not dated. At a nurses' station refrigerator, surveyors observed a plastic bag of food labeled with a resident’s name and dated more than a week earlier, along with three half-sandwiches wrapped in plastic without dates; the LPN present verified these findings. In a resident’s personal refrigerator, three undated bags of grapes with visible mold were found, and a CNA confirmed the grapes were moldy and undated. Facility policies required cold foods to be stored at least six inches above the floor, wrapped or in covered containers, labeled, and dated, and required resident refrigerators to be monitored daily, with food appropriately labeled and unsafe or moldy food discarded. These practices were not followed, resulting in the cited deficiency under the complaint investigation.
Unsanitary Kitchen Practices and Improper Dishwashing Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to unsanitary kitchen conditions, improper food labeling and dating, and failure to operate the dishwasher according to manufacturer and policy requirements. During an initial kitchen tour, they observed a plastic tray holding clean pitchers with a brown-like substance on it, and three open, three-shelf carts with crumbs and debris on the shelves where clean insulated plate lids and sleeves of disposable bowls, cups, and lids were stored. Multiple trays of juice in a reach-in refrigerator were open, unlabeled, and undated. In the walk-in refrigerator, surveyors found a plastic bag of bologna with only a freeze date and no thaw or use-by date; the bologna appeared slimy and lighter in color. The facility census was 67, with one resident identified as not receiving meals from the kitchen, and the deficiency was noted as having the potential to affect all residents receiving food from the kitchen. Surveyors also observed the high-temperature dishwasher in use and recorded a wash temperature of 168°F and rinse temperatures of 160°F, 176°F, 178°F, 178°F, and 178°F over five cycles, despite the machine label and facility policy requiring a minimum wash temperature of 150°F and a minimum rinse temperature of 180°F for hot water sanitizing. A staff member confirmed the dishwasher had not been running earlier that morning, verified it was a high-temperature machine that should rinse at a minimum of 180°F, and acknowledged the observations regarding the dirty tray, soiled carts, unlabeled juice, and improperly dated bologna. The staff member stated that items in the reach-in refrigerator were normally prepped the night before and asserted that the bologna always had that color before discarding it. Review of the dishwasher temperature logs for January through April 2026 showed repeated failures to meet required wash and rinse temperatures and numerous instances of missing documentation. In January, multiple wash temperatures were below the 150°F minimum, and several meals lacked recorded wash and rinse temperatures. February logs showed at least one sub-minimum wash temperature and many missing wash and rinse entries for various meals. March logs included at least one meal with no documented wash or rinse temperatures. April logs documented several wash temperatures below 150°F and rinse temperatures below 180°F, along with multiple days and meals where wash and/or rinse temperatures were not recorded at all. Facility policies on sanitation, kitchen infection control, and food receiving and storage required dishwashing to meet temperature and sanitation standards and refrigerated foods to be covered, labeled, dated, and used, frozen, or discarded by their use-by date, which was not consistently followed according to the survey findings.
Unsanitary Kitchen Conditions and Improper Sanitizer Levels
Penalty
Summary
The facility failed to maintain the kitchen area in a clean and sanitary condition and to ensure proper sanitization levels for food-contact surfaces, affecting all residents who received food from the kitchen. During an initial kitchen tour, surveyors observed that the shelf over the stove had accumulated grease and dust, the inside of the microwave contained built-up food from spatters, and the under-counter refrigerator had dried spills on the floor. In addition, the bucket of sanitizing solution used to wipe counters did not meet the correct sanitizer level. On a subsequent observation of the three-compartment sink used to wash and sanitize equipment and utensils, the sanitizer level again did not meet the correct standard. These findings were confirmed at the time of observation by the Dietary Manager, another staff member, and the Administrator in Training, and were cited as non-compliance under a complaint investigation.
Unsanitary Food Storage and Preparation Practices in Dietary Services
Penalty
Summary
The deficiency involves the facility’s failure to store and prepare food in a safe and sanitary manner, as observed during a kitchen tour. Surveyors observed dried, splattered food on the outside of a free-standing oven next to the stove, with food drips in various colors and a greasy, sticky surface that was greasy to the touch. The floor between the oven and stove was covered with crumbs, a plastic cap, and a dried, cracked food spill several inches in diameter. The black plastic cover of the ice machine filter was sticky and dusty. On a nearby food preparation counter, there were eight bowls pre-filled with dry cereal that were undated and unlabeled, and a lidded container partially filled with a yellow greasy substance that was also unlabeled and undated. Additional observations showed that a reach-in freezer/refrigerator used for open condiments, resident food from visitors, snacks, and beverages had dried food drips on the exterior and interior in multiple colors, and smeared, dried white liquid on the refrigerator shelves. Inside this unit, surveyors found a gallon of whole milk past its use-by date with yellow fluid and white clumps remaining, ten dessert bowls of fruit with no labels or dates, and an open, undated ketchup bottle with a broken, missing lid that could not be closed. In dry storage, a case of canned tomato juice was stored directly on the floor. In the walk-in refrigerator, there were multiple unlabeled and undated food items, including a bag of white lunch meat, containers and bowls of fruit, red gelatin with fruit, red liquid in glasses, and small bowls of coleslaw. In the walk-in freezer, an unopened case of hotdogs was stored on the floor. Dietary staff member #159 verified these findings at the time of observation, and the deficiency was investigated under a specific complaint number, with the potential to affect all 35 residents in the facility.
Failure to Maintain High-Temperature Dishwasher per Manufacturer Standards
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its high‑temperature dishwasher operated at manufacturer‑required temperatures and cycles for proper sanitation of dishware and utensils. Surveyor observations showed that the dishwasher’s posted minimums were a wash cycle of 159°F, pump rinse of 160°F, and final rinse of 180°F at 20 psi. When the machine was observed running, the wash gauge moved to 162°F, but the pump rinse and final rinse gauges did not move, and the machine did not activate the pump rinse or final rinse cycles while trays were conveyed through. Multiple trays were observed passing through the dishwasher without the rinse cycles engaging. The dietary manager confirmed that while water was spraying continuously inside the machine, the rinse cycles did not start as expected and that the dishwasher was a high‑temperature machine. On a follow‑up observation the next day, while the dishwasher was idle, the gauges read 164°F for wash, 162°F for pump rinse, and 120°F for final rinse. When the dishwasher was run, the wash gauge read 150°F, the pump rinse 160°F, and the final rinse 170°F over five cycles, which did not meet the manufacturer’s specified minimums of 150°F wash, 160°F pumped rinse, and 180°F final sanitizing rinse at 20 psi. The maintenance director and dietary manager verified that the dishwasher was not washing or rinsing dishes per manufacturer recommendations. Review of the dishwasher temperature logs for the previous four months showed multiple days when the final rinse temperatures did not meet the required minimums. Facility policies required that dishwashing meet temperature and sanitation standards and that dishwashing machines be operated according to manufacturer instructions, but the recorded temperatures and observed operation did not comply with these standards.
Failure to Monitor and Document Food Temperatures for All Meals
Penalty
Summary
The deficiency involves the facility’s failure to consistently monitor and document food temperatures in accordance with its policy and the Ohio Uniform Food Safety Code. Review of dietary food temperature logs for March 2026 showed multiple missing meal temperature entries, including missing breakfast and lunch temperatures on several dates, missing breakfast, lunch, and dinner temperatures on other dates, and missing dinner temperatures on numerous additional dates. Similar review of April 2026 logs revealed missing breakfast and lunch temperatures on multiple days, missing breakfast, lunch, and dinner temperatures on several days, and missing lunch or dinner temperatures on other dates. The facility’s policy required that temperatures of TCS (time/temperature control for safety) foods be taken and properly recorded for each meal. Food committee meeting minutes for March 2026 documented resident reports that fries, baked potatoes, and tenders were undercooked, pork loin was overcooked, and broccoli and other vegetables were sometimes overcooked or undercooked; residents also reported undercooked baked potatoes and eggs served cold. During an observation of lunch meal preparation and temperature checks on 04/20/26, surveyors, along with the Dietary Manager and another dietary staff member, noted that the March and April meal temperature logs contained missing meal temperatures. In an interview at the time of this observation, the Dietary Manager and dietary staff member confirmed the missing documentation prior to serving meals. The facility census at the time was 110 residents, and the deficiency was investigated under Complaint Number 2961159.
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