Based on observation, interview and record review the facility failed to maintain sanitary conditions as evidenced by: 1) Dietary Staff put used paper towels on a food prep area. 2) Dietary Staff touched the lid of a dirty garbage can with clean hands and did not wash their hands. 3) Dietary Staff did not have a garbage can to discard dirty paper towels. 4) Dishes were not properly sanitized. 5) Potatoes were stored uncovered under meat prep area. 6) Cooking appliances were not cleaned. 7) Dietary Staff were not wearing proper hair and facial covering. The cumulative effects of the systemic failures resulted in an Immediate Jeopardy was declared on 2/1/18 at 2:30 p.m., and reported to Administrator and CEO due to unsanitary conditions and cross-contamination in the kitchen that had the potential for food borne illness that could cause serious illness and death. Findings: During the initial tour of the kitchen on 1/29/18 at 08:20 a.m., The hand washing sink did not have a garbage can available to discard paper towels after washing hands. Past Executive Chef found a garbage can for another area and placed it by the hand washing sink. During an observation on 1/31/18 at 12:20 p.m., kitchen staff were seen washing hands at the hand washing sink and walking over to the garbage can past the dishwasher area. They were seen using a clean hand to push open a dirty trash can lid to dispose the used paper towels. During an observation on 1/31/18 at 12:25 p.m., Food Service H used hand washing sink to wash hands, walked towards the garbage can and decided not to use it. She went to the food prep counter and put down the used paper towel. Food Service H then went to get knife and cutting board, came back to food prep counter, wiped the area off with the used paper towel, then put down the cutting board, and started to cut the vegetables. Food Service H paused, washed hands, and the used paper towels from that hand washing ended up on the cutting board, contaminating the food prep surface. During an interview on 1/31/18 at 2:40 p.m., Food Service H stated she did not want to use the garbage can with the lid that had to be pushed by hand because she knew it would contaminate her hands. Food Service H stated there had been a garbage can by the hand washing sink until it was broken and her supervisors had not gotten a replacement. During an observation on 1/31/18 at 9:00 a.m., the cooking appliances were dirty. The 'Hot Hold' warming oven had burnt residue at bottom of compartment. The Warming Oven next to the Hot Hold oven had baked on dirt on bottom shelf of oven, baked on food on racks, and the glass doors had a brown substance clinging to the glass. The large stand alone burner for huge pots and pans had food residue on the pan rack over the burner and the top of the appliance had fresh and burnt on food residue. The grill section of the main range had food residue on the rack and grease and black crumbs of food particles under the grill and on the supporting edges of the grill. The rack on top of the range to support the pans had food particles on it and under the rack there was aluminum foil covered with grease and burnt food residue. The 2 main ovens had burnt on food residual on the bottom and on the oven racks. The plate warmer has brown staining along the back of the compartment. During an interview on 1/31/18 at 9:10 a.m., Food Service H stated that she did not clean the appliances but a person comes in at night to do all the cleaning. During an observation and concurrent interview on 2/1/18 at 11:10 a.m., Food Service E acknowledged that the appliances were dirty and explained that it was from cooking that morning such as the pan on the large stand alone burner had boiled over. Food Server E stated that the facility had a company to come in and clean the kitchen during the night. Prep cooks were responsible to clean their work areas and place used cooking items to the dishwashing areas. During an observation on 1/31/18 at 9:15 a.m., clean cooking utensils and clean plastic mugs for the meal trays were stored in open bins, right next to the dishwasher. The cooking utensils were jumbled in the bins and heaped up above the rim of the bins. During an observation on 2/1/18 at 11:40 a.m., the clean mugs stored by the dishwasher, had visible food particles. The clean cooking utensils stored in the open bins next to the dishwasher had traces of food on the inside surface of the bin, water collected on the bottom of the bin and a candy wrapper mixed in with the utensils. During an observation of the ice maker on 1/31/18 at 9:30 a.m., the outside of the ice bin was visibly dirty. The ice bin was full of ice. Near the top of the bin was an area of brown substance, and when wiped with a dry white cloth a gray unknown substance was found. A log about the cleaning of the ice maker was not located with the appliance. During an interview on 2/1/18 at 12:30 p.m., Engineer stated that maintenance of the kitchen equipment was contracted out and the ice maker in the basement was maintained by a separate company. During an interview on 1/31/18 at 2:35 p.m., Food Service F stated that he thought the dishwasher used heat to sanitize the dishes. He stated the testing of the dishwasher with test strips was three times a week. During an interview on 2/1/18 at 11:00 a.m., Food Service E stated the dishwasher sanitizes the dishes by heat and the water temperature was checked three times a day when washing the dishes from the last meal served. During an observation on 2/1/18 at 11:50 a.m., the food service person washing the dishes ran the temperature test strip through the dishwasher. The test strip failed to react to the heat. A second test was ran because it was thought the test plate was removed before the cycle completed. Two more temperature tests were done and still the strip failed to react to the heat. New RD stated she would find a thermometer to run through the dishwasher to test the temperature again. During an interview on 2/1/18 at 9:00 a.m., Food Service F stated that they check the dishwasher temperature with the EcoLab strips. They do not have a thermometer. The temperature they had documented on the daily temperature log were based on readings from the temperature gauges attached to the dishwasher machine, not from test strips. Food Service F stated the EcoLab strips stopped turning black about a week ago. The turning of the strips from white to black would indicate that the temperature is appropriate for disinfecting the dishes. During an interview on 2/1/18 at 9:15 a.m., Food Service G stated that the EcoLab strips stopped working about five to six days ago, but he did not alert management about this issue. Food Service G stated he did not inform management because he figured somebody else would do it. During the initial tour of the kitchen on 1/29/18 at 08:20 a.m., Past Executive Chef had a baseball cap on to cover his hair and did not have a beard cover over his facial hair. Two food service staff had on hair nets but did not covering all of their hair. During an interview on 1/31/18 at 2:35 p.m., Food Service F sported a mustache and when asked if he needed to wear a beard cover he stated he did not need to wear one. During an observation on 2/2/18, Food Service E was wearing a hair net but it was not covering all of her hair. When asked if she knew that some of the staff did not have their hair completely covered, she stated OK I will go get a net for my hair. During an observation on 1/31/18 at 12:00 p.m., Food Service F put on an cloth oven mitt to place the the warmed metal plate holders onto the food trays and moved the food trays down the line wearing the oven mitt. The oven mitt was visibly soiled from prior uses. During on interview on 1/31/18 at 2:35 p.m., Food Service F stated that his duties included helping at tray line and he uses the oven mitt on the hot metal plates. Food Service F stated that the oven mitts are not washed and thrown away when worn out. During on observation on 1/31/18 at 9:15 a.m., the steam table pans, stored on shelving between the 3 compartment sink and the food prep tables, were found stacked together and wet. During an observation on 2/1/18 at 11:30 a.m., the food service staff was seen washing steam table pans at the 3 compartment sink and adding them to a stack of pans on the storage shelf, instead of onto a surface where they could air dry. During an observation on 2/2/18 at 8:30 a.m., steam pans on the shelving by the 3 compartment sink were stored wet. During an observation on 1/31/18 at 9:15 a.m., the food preparation table had 3 plastic bins with red onions, white onions and potatoes and the lids were loose. The lid over the potatoes only covered about half of the potatoes. During on observation on 2/1/18 at 1130 a.m., the food preparation table with the bins of onion and potatoes was being used to prepare meat. The meat was on a cutting board with no sides and meat juice was being released from the meat. The plastic bin holding the potatoes was under this food prep table and the lid on the potato bin left the potatoes uncovered. The cumulative effects of the systemic failures resulted in an Immediate Jeopardy was declared on 2/1/18 at 2:30 p.m., and reported to Administrator and CEO due to unsanitary conditions and cross-contamination in the kitchen that had the potential for food borne illness that could cause serious illness and death. During an observation and concurrent interview on 2/2/18 at 9:00 a.m., pans had been placed under the meat prep table. New Executive Chef stated thought if something dripped onto the bottom surface of the pan it would not matter, as the pans could be rewashed. Pans were sent to the dishwasher. The Immediate Jeopardy was abated on 2/2/18 at 3:20 p.m. Dietary Staff followed their plan of action, dated 2/2/18 at 11:20 a.m , as follows: 1) The facility bought a garbage can for the kitchen, 2) In-service and education to dietary staff on maintaining infection control practices, 3) Ice machine was cleaned and logs for cleaning and maintenance revised, 4) Silicon oven mitts were purchased, 5) Identified that dietary staff needed to use correct temperature test strips to verify sanitation by the dishwasher, 6) Throw out all contaminated vegetables and relocated the vegetables, 7) In-serviced on not stacking wet pans and ensuring steam pans were placed on drying rack, 8) In-service dietary staff on hair and facial covering. Dietary Manager will monitor use of hair/facial covering daily. The facilities Sanitation and Infection Prevention/Control policy dated 1/2016 instructed that All associates associated with the handling of food shall wash hands, Use sinks designated for hand washing For the kitchen it is indicated that the food contact surfaces of all cooking equipment shall be kept free of encrusted grease deposits and other accumulated soil. Nonfood contact surfaces of equipment . shall be cleaned as often as is necessary to keep the equipment free of accumulation of dust, dirt, food particles and other debris. The dishwasher temperatures procedure instructed that once a day, run a test strip through the dishwasher to verify the surface temperature of a dish. The test strip must verify that the surface temperature of the plate reached 160 degrees, and in the event of inappropriate temperature the director must investigate. Other parts of the policy include: Hair restraints are worn by all when in the kitchen, and the storage of pots, dishes and flatware section instructed the following: air dry food contact surfaces including pots, dishes, flatware and utensils before storage . Do not stack or store when wet. The ice machine's manufacture guidelines documented the storage bin must be cleaned and sanitized regularly to maintain a sanitary environment, and frequency of cleaning man need to be adjusted to local conditions and environment.

Based on observation, interview and record review the facility failed to have a trash receptacle located at the hand washing sink which led to the inability of staff to dispose of the used paper towels causing cross-contaminated. This failure resulted in an Immediate Jeopardy called on 2/1/18 at 2:30 p.m., due to unsanitary conditions and cross-contamination that could affect the health and safety of residents causing serous illness and death. This was reported to Administrator and CEO at above date and time. (see F 812) Findings: During the initial tour of the kitchen on 1/29/18 at 08:20 a.m., The hand washing sink did not have a garbage can available to discard paper towels after washing hands. Past Executive Chef found a garbage can for another area and placed it by the hand washing sink. During an observation of the kitchen on 1/31/18 at 8:30 a.m., the hand washing sink did not have a garbage can nearby. Staff had to walk past the dishwasher area of the kitchen to a trash can with a lid that had to be pushed inwards by hand to place garbage inside. During an observation on 1/31/18 at 12:20 p.m., kitchen staff were seen washing hands at the hand washing sink and walking over to the garbage can past the dishwasher area. They were seen using a clean hand to push open a dirty trash can lid to dispose the used paper towels. During an observation on 1/31/18 at 12:25 p.m., Food Service H used hand washing sink to wash hands, walked towards the garbage can and decided not to use it. She went to the food prep counter and put down the used paper towel. Food Service H then went to get knife and cutting board, came back to food prep counter, wiped the area off with the used paper towel, then put down the cutting board, and started to cut the vegetables. Food Service H paused, washed hands, and the used paper towels from that hand washing ended up on the cutting board, contaminating the food prep surface. During an interview on 1/31/18 at 12:30 p.m., Past RD stated she had requested the hand washing sink to have a new garbage can about a week ago. During an interview on 1/31/18 at 2:35 p.m., Food Service G stated that the garbage can broke about a week ago and they asked their bosses for a replacement. During an interview on 1/31/18 at 2:40 p.m., Food Service H stated she did not want to use the garbage can with the lid that had to be pushed by hand because she knew it would contaminate her hands. Food Service H stated there had been a garbage can by the hand washing sink until it was broken and her supervisors had not gotten a replacement. Durning an observation on 2/1/18 at 11:00 a.m., the kitchen's hand washing sink lacked a garbage can for the used paper towels. Durning an interview on 2/1/18 at 11:00 a.m., Food Service E stated that a replacement garbage can had been ordered and would be there in a few days. Durning an interview on 2/1/18 at 12:30 p.m., requested a copy of work orders or requisitions and invoices for repairs for the kitchen. Food Service E stated that she did not have any work orders, that requests were made verbally or by telephone. During an interview on 2/1/18 at 12:50 p.m., Engineer stated that the kitchen maintenance was contracted out. The facilities maintenance department filled requests for the kitchen like changing light bulbs, adding bulletin boards or fixing clogged drains. Requests were made by phone and the maintenance department did not keep a log of repairs they did in the kitchen. This failure resulted in an Immediate Jeopardy called on 2/1/18 at 2:30 p.m., due to unsanitary conditions and cross-contamination that could affect the health and safety of residents causing serious illness and death. This was reported to Administrator and CEO at above date and time. (see F 812) During an interview on 2/2/18 at 9:00 a.m., Food Service E stated that she communicated with the past food service's General Manager by leaving notes and complained that they were not responsive to her requests. Food Service E stated that she rarely communicated with the facilities administration, she reported to the General Manager. The Immediate Jeopardy was abated on 2/2/18 at 3:20 p.m. The facility bought a new garbage can and Dietary Staff were in-serviced in how to maintain infection control practices. The facilities policy on Hand Hygiene, dated 1/2016, specified All hand wash sinks should be easily accessible with nothing blocking their access in food production, food service and dishwashing areas. Hand wash sinks . should be clean and stocked with soap, paper towels, a covered waste receptacle and a Hand Wash sign. Food safety code documents that a trash receptacle must be located at the hand washing sinks to discard disposable towels.