Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in a sanitary manner, in accordance with professional standards for food service safety, as evidenced by: 1. Rodent droppings and evidence of nesting (collection of clutter, trash, and debris) was found in the cooking line area of the kitchen, as well as an accumulation of grease and black grime and food, this had the potential to transmit disease to patients by contaminating food and food contact surfaces. In addition, a convection oven (oven that has fans to circulate air around food), a steamer, three ovens, one fryer and a broiler had an accumulation of grease and food grime build-up. This had the potential to attract pests and for microorganism (a microscopic organism, especially a bacterium, virus, or fungus) growth that could be inadvertently transferred to food. 2. The industrial stand mixer had crusted dry substances on the protection grate, the steam jacketed kettles had crusted yellow food inside the kettle, and the convection oven had black and yellow grime build-up and the side of the unit was rusted. This had the potential for microorganism growth and to attract pests. 3. Raw turkey was thawing and the juices were found to be dripping from storage boxes onto raw beef defrosting right next to it in the walk-in refrigerator. This cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another) had the potential to cause foodborne illness (food poisoning-caused by food contaminated with bacteria, viruses, parasites, or toxins). 4. In the walk-in refrigerator designated for dairy, there were plastic risers that food was stacked on top of and underneath there was spilled milk and yellow crusty looking substance on the floor that appeared to be spilled eggs. This had the potential for microorganisms to grow and to attract pests. 5. Multiple drawers were missing under food prep tables, and food crumbs had accumulated in the tracks of the missing drawers. This had the potential for microorganisms to grow and to attract pests. 6. Two frozen vegetable patties were uncovered in the freezer. This had the potential for food to become contaminated and cause food-borne illness. 7. Hand hygiene was not performed by Dietary Aide 2 who was handling ready to eat food. This had the potential to cause food-borne illness. Rats are especially dangerous in healthcare facilities because these pests carry disease and spoil food with the bacteria and viruses they harbor in their saliva and droppings. This failure led to 15 out of 16 medically compromised residents who received food from the kitchen, to be at risk for food-borne illness from contaminated food. Findings: 1. During the initial tour of the kitchen and concurrent interview with the Executive Chef (Chef) on February 26, 2024, at 11:35 a.m., at the cooking line where food was prepared for the residents, there were rodent droppings and evidence of nesting identified under the fryer and oven range. The Chef stated, they had a rat problem and the kitchen is very old, equipment is not working, and it is very hard to clean. The Chef further stated, several failed attempts have been made to scrape off and remove the food and grime buildup. One of the fryers was out of service and had food and grime buildup. Three of the four ovens were out of service and the spaces between the three stoves which housed the gas lines had an accumulation of grease, trash, black food grime and rodent droppings and evidence of nesting. The floor under the equipment also had an accumulation of grease, food grime and trash. There were rat droppings, confirmed by the Chef and evidence of rodent nesting, small pieces of torn papers, and piles of trash under the ovens. A round greyish color food item was pulled out from the oven and the Chef stated, it was a hamburger patty. During a concurrent observation and interview with the Chef, on February 26, 2024, at 11:40 a.m., at the cooking line, the convection oven, the steamer, three ovens, two fryers and a broiler, had an accumulation of grease and food grime buildup. The knobs had a sticky brown residue, the inside of the convection oven had a black build-up, and the door of the oven was crusted with yellow and black grime. The steamer had yellow and black build-up. The non-functioning fryer was covered with a metal plate and underneath the cover there was oil and food grime buildup. The broiler above the stove top was crusted with black food grime and grease. During an interview on February 27, 2024, at 10:54 a.m., with the Service Technician (ST) from [Company Name] pest control company. ST stated rats have been an issue for a while, he was recently at the facility for an infestation. ST stated, he suspects the rats may be using the sewer lines in the kitchen to gain access and can come in through any holes in the kitchen. During an observation in the kitchen, on February 27, 2024, at 11:07 a.m., the back door of the dry storage room that leads to the loading dock had a gap under the door and the gasket (seals the gap between two surfaces) around the door was falling off. During an interview with the Clinical Nutrition Manager (CNM), on February 28, 2024, at 2:39 p.m., CNM stated if a space is accessible, it should be clean and free of rat droppings. During an interview with the Chief Administrative Officer (CAO), on February 29, 2024, at 3:17 p.m., he stated the rodent issue was never brought up in the daily safety huddle meetings. The CAO stated all the hospital upper management team gets together daily to talk about safety issues in the hospital/SNF. He stated that the Food and Nutrition Services Department staff do attend these meetings but never brought up the rat infestation in the kitchen. During a review of the [Company Name] summary of services report, dated February 16, 2024, indicated, Recommendation: Cracks or damage to wall allowing pest access. Please repair to prevent pest entry. A hole in wall in drink cage I (ST) pointed out to the Patient Service Manager (PSM)], Status: PENDING, Date: 11/30/2023. An accumulation of food products from damaged goods noted. Please remove food product to prevent attraction by pests. Main kitchen cooking line. Status: PENDING, Date: 04/06/2023. A review of an email, dated February 16, 2024, at 8:18 a.m., indicated the [Company Name] pest control company the facility's managers were notified regarding Large rat spotted in dish room and roaches spotted in cold production area basement kitchen. A review of the FANS (food and nutrition services) Pest Control Log indicated: -On January 12, 2024, a rodent was seen in the tray line area. -On January 24, 2024, roaches were seen in the tray line area. -On January 27, 2024, roached were seen in the tray line area. -On January 28, 2024, roaches were seen in the cold prep area and in the toaster. -On February 3, 2024, a rodent was seen in the kitchen. -On February 16, 2024, a rodent and roaches were seen in the dish room and cold prep areas. A review of the facilities policy titled Pest Control, dated January 2023, indicated The Food and Nutrition Services Department/Dining Services shall be free of all rodents and insects. Associates are instructed to report pest sightings to management . A review of the company's policy and procedures titled Sanitation and Infection Prevention and Control Program Overview, dated January 2023, indicated .Proper sanitation and infection control practices are observed in all phases of food production and service . During a review of the FDA Federal Food Code, dated 2022, 6-501.111 indicated, The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by: (A) Routinely inspecting incoming shipments of food and supplies; (B) Routinely inspecting the premises for evidence of pests; (C) Using methods, if pests are found, such as trapping devices or other means of pest control as specified under 7-202.12, 7-206.12, and 7-206.13; and (D) Eliminating harborage conditions. In addition, Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. During a review of the FDA Federal Food Code, dated 2022, 4-601.11 indicated, (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. In addition, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. During a review of the FDA Federal Food Code, dated 2022, 4-602.13 indicated, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. In addition, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. 2. During an observation of the cook's bulk preparation area, and concurrent interview with the Executive Chef (Chef), on February 26, 2024, at 11:19 a.m., there was an industrial stand mixer that had crusted food on the protection grate. Per Chef he agreed it was not from recent use. There was also yellow colored crusted food on the insides of two steam jacket kettles (uses steam heat to cook large amounts of food). The Chef stated the kettles should be cleaned after use and they were not currently in use. Next to the kettle was a convection oven, the side of the oven was a rust color, inside there was black and yellow grime build-up. Chef stated, there is only one oven they can use and do not have time to clean it because of the large volume of meals they have to prepare. During an interview with the Clinical Nutrition Manger (CNM) on February 28, 2024, at 2:39 p.m., the CNM stated that the cook's bulk preparation area equipment should be cleaned after every use and not have any crusted food on it. During a review of the facility policy titled Sanitation and Infection Prevention and Control Program Overview, dated January 2023, indicated Proper sanitation and infection control practices are observed in all phases of food production and service. During a review of the FDA Federal Food Code, dated 2022, 4-601.11 indicated, (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. In addition, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. During a review of the FDA Federal Food Code, dated 2022, 4-602.13 indicated, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. In addition, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. 3. During an observation in the walk-in refrigerator and concurrent interview with the Executive Chef (Chef) on February 26, 2024, at 11:01 a.m., there were multiple stacked boxes of raw beef defrosting. Next to the raw beef there were multiple stacked boxes of raw turkey defrosting, the raw turkey boxes were positioned and hung over the raw beef and juices from the turkey were seen dripping onto the boxes of raw beef. Chef stated, the box of turkey should not be defrosting on top of the beef due to possible cross contamination. A review of the facility's policy and procedure titled Food and Supply Storage, dated January 2023, indicated .Refrigerated storage .separate goods by category (meat, fish, poultry .if raw animal products are stored on the same rack, store them in the following order .whole cuts of beef, pork, ground meat and poultry . During a review of the FDA Federal Food Code, dated 2022, 3-302.11 indicated, Except when combined as ingredients, separating types of raw animal foods from each other such as beef, fish, lamb, pork, and poultry during storage, preparation, holding, and display by: (b) Arranging each type of food in equipment so that cross contamination of one type with another is prevented . In addition, It is important to separate foods in a ready-to-eat form from raw animal foods during storage, preparation, holding and display to prevent them from becoming contaminated by pathogens that may be present in or on the raw animal foods. With regard to the storage of different types of raw animal foods as specified under subparagraph 3-302.11(A)(2), it is the intent of this Code to require separation based on anticipated microbial load and raw animal food type (species). Separating different types of raw animal foods from one another during storage, preparation, holding and display will prevent cross-contamination from one to the other. The required separation is based on a succession of cooking temperatures as specified under § 3-401.11 which are based on thermal destruction data and anticipated microbial load. For example, to prevent cross-contamination, fish and pork, which are required to be cooked to an internal temperature of 145°F for 15 seconds, shall be stored above or away from raw poultry, which is required to be cooked to an internal temperature of 165°F (<1 second, instantaneous) due to its considerably higher anticipated microbial load. 4. During the initial tour of the kitchen an observation and concurrent interview was conducted with the Executive Chef (Chef), on February 26, 2024, at 11:12 a.m., in the walk-in refrigerator labeled number 22. There were plastic risers used to store milk and eggs, and under the risers there was spilled milk. In the back corner on the floor there was a yellow crusted looking substance that appeared to be spilled eggs. Chef stated spills should be clean up immediately. During an interview with the Clinical Nutrition Manager (CNM) on February 28, 2024, at 3:30 p.m., the CNM stated, that spills should be cleaned up as they occur. During a review of the FDA Federal Food Code, dated 2022, 4-602.13 indicated, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. In addition, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. 5. During an observation and concurrent interview was conducted with the Executive Chef (Chef), on February 26, 2024, at 11:12 a.m., multiple drawers were missing under food prep tables, in the cook's bulk preparation area, cooking line and cold food preparation area, the tracks used to hold the drawers had an accumulation of yellow food grime. Chef stated, the tracks of the drawer should be kept clean and not have an accumulation of food grime. During an interview with Dietary Aide (DA1), on February 27, 2024, at 10:38 a.m., DA1 stated that the drawers had been missing for years. During an interview with the Clinical Nutrition Manager (CNM), on February 28, 2024, at 2:39 p.m., CNM stated that the drawer tracks should be clean and free of food build-up. During a review of the FDA Federal Food Code, dated 2022, 4-602.13 indicated, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. In addition, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. 6. During the initial tour of the kitchen and concurrent interview with the Executive Chef (Chef) on February 26, 2024, at 10:51 a.m., There were two frozen vegetable patties, out of their packaging, in the freezer. The Chef stated all food should be covered. A review of the facility's policy and procedure titled Food and Supply Storage, dated January 2023, indicated .All food .used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption .wrap food tightly to prevent cross contamination . During a review of the FDA Federal Food Code, dated 2022, 3-301.11 indicated, (A) FOOD shall be protected from cross contamination by . (4) storing the food in packages, covered containers, or wrappings;. In addition, Food that is inadequately packaged or contained in damaged packaging could become contaminated by microbes, dust, or chemicals introduced by products or equipment stored in close proximity or by persons delivering, stocking, or opening packages or overwraps. Packaging must be appropriate for preventing the entry of microbes and other contaminants such as chemicals. These contaminants may be present on the outside of containers and may contaminate food if the packaging is inadequate or damaged, or when the packaging is opened. The removal of food product overwraps may also damage the package integrity of foods under the overwraps if proper care is not taken. 7. During an observation, on February 27, 2024, at 11:50 a.m., kitchen staff was plating meals for residents. Dietary Aide (DA2) was observed answering his phone, talking on the phone, and clipping the phone back on his pants while wearing gloves. DA2 did not change his gloves or wash his hands and continued to prepare resident meal trays. During an interview, on February 28, 2024, at 3:30 p.m., with the Director of Food and Nutrition Services (DFANS), and the Regional Supervisor (RS), was conducted. The RS stated, DA2 did not follow proper hand hygiene protocol, he should have performed hand hygiene and changed his gloves after answering his cell phone. During a review of the company's policy and procedures titled Sanitation and Infection Prevention and Control Program Overview, dated January 2023, indicated .Proper sanitation and infection control practices are observed in all phases of food production and service .proper hand hygiene .disposable glove use . On February 26, 2024, at 4:10 p.m., an immediate jeopardy (IJ) (immediate corrective action is necessary because the facility's noncompliance with one or more of those requirements has caused, or is likely to cause, serious injury, harm, impairment or death to a resident receiving care in a facility) was called under 483.60(i)(1)-Procure food from sources approved or considered satisfactory by federal, state or local authorities and 483.60(i)(2)-Store, prepare, distribute and serve food in accordance with professional standards for food service safety The facility was notified of the IJ under federal tag 812: The facility did not Store, prepare, distribute, and serve food in accordance with professional standards for food service safety when there was rodent droppings and evidence of nesting identified on the main cooking line in the kitchen, as well as the presence of excessive black grime and grease build-up and old food on the floor and kitchen equipment. A build-up of crumbs and black grime found on and under equipment and proper hand hygiene was not performed by one staff member handing ready to eat food. On February 26, 2024, the facility provided a Corrective Action Plan and indicated the following will be implemented immediately to address the sanitation issues in the kitchen: 1. All surface areas in the kitchen were cleaned. 2. All foods have been removed from the Skilled Nursing Facility (SNF). 3. An emergency request for pest control to come onsite and perform extermination services. 4. A restoration company will be working all night to perform deep cleaning of the kitchen and Evaluate any wall penetrations and perform repairs as needed. 5. All food preparation surfaces will be sanitized immediately before any food preparation. 6. The diet list for the 15 residents have been sent to the dietician. 7. Pre-packaged meals and beverages will be provided to residents on regular diets. 8. For residents on altered texture diets, the diets will be downgraded to pre-packaged purees and the residents will be provided with supplements. 9. After completion of the terminal clean, restoration, and extermination, we will have a third- party environmental company come onsite and perform an inspection. The IJ was lifted on February 29, 2024, at 4:30 p.m., after an acceptable corrective action plan was implemented and carried out, and verified through observation, interview, and record review.