Based on the kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. The facility failed to ensure that the dietary staff was trained and knowledgeable about the proper procedures for hand hygiene, disposable glove use, food storage, and proper sanitation practices in the kitchen. Specific instruction on hand hygiene, food handling, and sanitation is important in health care settings serving nursing home residents due to the risk of serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices represent a potential source of pathogen exposure. Findings include: During the initial kitchen tour on 09/28/2020 from 10:33 AM until 11:25 AM with the Patient Services Manager (PSM) and the Quality Assurance (QA) Specialist, the hand sink nearest to the door did not have paper towels in the dispenser or a garbage can to dispose of paper towels. Employee C, a food preparation cook, was observed at 10:35 AM to doff one of his disposable gloves, take his phone out of his pocket with his bare hand, use the phone and return it to his pocket, take off his other glove and discard it, and don a new pair of gloves without washing his hands. He was observed again at approximately 10:43 AM to doff his gloves and don a new pair of gloves without washing his hands. Employee D was observed at 10:39 AM to open a bag of sliced bread and remove six slices of bread with her bare hands. She laid them out on the cutting board, went to the dish room to retrieve a spreader, went out of the kitchen to the retail section of the cafeteria and fill a quart size cup with chicken salad and return to the cutting board. She did not have gloves on, and she then went to wash her hands. After washing her hands and taking the paper towel to dry them, she turned the water off with her bare hand, thereby recontaminating her hand. She dried her hands, disposed of the paper towels, and donned a pair of disposable gloves. She then went back to the cutting board. She did not discard the bread slices but continued to make the sandwiches using the bread. The three door reach-in cooler had standing water in the bottom of the unit. No internal thermometer was found inside the unit. The salad bar cooler had no internal thermometer. The daily prep cooler had a bag of raw chicken pieces submerged in juice lying on a shelf with no tray under it to guard against leakage (Photographic evidence obtained). No internal thermometer was found. The walk in cooler had no internal thermometer. The walk in freezer had no internal thermometer. Food was observed on the floor (Photographic evidence obtained). In the ware washing area of the kitchen, stainless steel mixing bowls and baking pans were found to be wet nesting, stacked on top of each other with no chance to air dry. Flies were observed in the kitchen. Observation of the dish room and dish washing processes revealed Employee F working in the dish room by himself. He loaded the dirty dishes on the conveyor belt and then went to the other end of the machine and unloaded the clean dishes without doffing his contaminated gloves, washing his hands, and donning new gloves. He continued to do this without changing gloves or washing his hand during the whole observation from 10:33 AM until 11:25 AM. The hand washing sink in the dish room was blocked by several carts stored in the area. Flies were observed in the dish room. During a follow-up tour and lunch meal service observation on 09/29/2020 from 11:35 AM until 1:37 PM, the hand sink nearest to the door had no trash can to dispose of paper towel. The three door reach-in cooler still had standing water in the bottom and no internal thermometer. The QA Specialist moved a cardboard box that was sitting in the water. She stated she was not sure where the water was coming from. Stainless steel bowls were observed on the shelves in the ware washing area wet nesting. The QA Specialist stated they would have to get more shelving to allow for proper air drying of the pots and pans. The QA Specialist acknowledged that the missing internal thermometers did not just happen recently, and that the coolers had probably been without an internal thermometer for some time now. She did not know how long. One of the reach-in coolers near the tray line had an external digital thermometer display that was covered by a piece of tape. The QA Specialist laughed and pulled the tape off to indicate the thermometer was working. She stated, I keep it covered because I don't want the staff to rely on the external thermometer reading only. I want them to check the internal thermometer. The cooler did not have an internal thermometer. Standing water was observed on the floor of the kitchen under the prep sink and the counter. Employee F was instructed by the QA Specialist to mop up the floor. Water was observed on the floor under a shelving unit in the ware washing area of the kitchen. Flies were again observed in the kitchen. The food mixers in the bakery prep room were both dirty with crusted on food. The large mixer's mixing mechanism had rust and the outer seal was peeling off into the mixing bowl (Photographic evidence obtained). During an interview with the QA Specialist and the Chef at 1:29 pm, the Chef stated that the mixers were recently brought over from the main hospital and they have not been used. During the lunch meal service observation from 11:55 AM until 12:40 PM, Employee E, Culinary Supervisor, was observed to be plating food on the tray line. She did not change gloves when they became contaminated. QA Specialist, Employee I, Patient Services Supervisor, and Employee C all opened the door to the food warmer behind the tray line at different times during the meal tray preparations. After they touched the latch to the food warmer, Employee E then opened the door by touching the latch. After she touched the latch, she did not change her gloves. She went to the tray line and continued to plate the food with the same gloves. She then opened a bag of hamburger buns and took one bun out of the bag and put in on a plate with her contaminated gloves. She prepared a hamburger. She then went to the warmer, opened the door, and plated French fries on the plate with the hamburger. After putting the plate on cart for service, she went back to the tray line and kept plating food without changing her gloves or washing her hands. During an interview with Employee D on 09/29/2020 at 12:45 PM, she stated that she was not aware that she did not have gloves on when she took the bread out of the bread bag on 09/28/2020. She stated she should have had gloves on while making sandwiches. She did not remember shutting the faucet off with her bare hand after washing her hands. She has received training on hand hygiene and glove use. When asked what she should have done after touching the bread with her bare hands, she stated, I should have thrown it away. During an interview with Employee C on 09/29/2020 at 1:05 PM, he stated he remembered he used his phone on 09/28/2020, and that he keeps it in his back pocket while working. He did not remember whether or not he washed his hands after using the phone and prior to donning new disposable gloves. He stated he knew he should do that and has had training on hand hygiene and glove use. During an interview with the QA Specialist on 09/29/2020 at 1:10 PM, she confirmed that there is not a hand washing sink in the area of the tray line. She indicated the nearest hand washing sink 20 feet from the tray line located in the prep area of the kitchen. She confirmed that it was not located close enough for accessibility by Employee E while plating the food, and it is not convenient for her to change gloves and wash her hands often enough. She stated that she was aware of the flies in the kitchen, and she knew the pest control company had come in the last month to treat for them. She stated she thought the problem was due to a drain in the kitchen and water backing up into the kitchen, but that had been fixed. A second observation of the dish room from 1:15 PM until 1:37 PM revealed Employee F rinsed the dirty lunch dishes, loaded the dish machine, and started the conveyor belt. He did not doff his disposable gloves or wash his hands and don clean gloves before he went to the other end of the dish machine and removed the clean dishes from the machine, thereby recontaminating the dishes. Water was observed on the floor of the dish room under the sink used to rinse the dishes prior to loading them into the dish machine. A swarm of flies was observed in the dish room near the standing water on the floor. Food debris was stuck on the stainless steel chute under the rinse sink in the dish room. During an interview with Employee F on 09/29/2020 at 1:30 PM, he stated there is a hand wash sink in the dish room and indicated the hand sink that was blocked by the stored carts. He stated he does not use it. He stated he washes his hands in one of the sinks in the kitchen. The nearest sink to the dish room in the kitchen was observed to be 35 to 40 yards from the rinse sink in the dish room. He confirmed he had not changed his gloves when he went from the dirty side of the dish room to the clean side. He stated he had been trained to change his gloves and wash his hands prior to unloading the clean dishes. He confirmed that there has been a problem for some time now in the dish room with flies swarming near the rinse sink and water standing on the floor of the dish room. During an interview with the contracted pest control company representative on 09/29/2020 at 1:35 PM, he stated that he had been in the facility kitchen on 09/28/2020, but was not made aware of the swarming flies in the dish room. He bent down and took his flashlight and showed this surveyor the stuck on food debris on the wall and the stainless steel chute under the rinse sink. He stated that is a good food source for the flies. He stated the standing water is also a big problem because the flies are attracted to it. During an observation of the Transitional Care South Unit nutrition room, seventeen individual nutritional supplements were found to be expired (Photographic evidence obtained). One carton expired 09/14/2019. During an interview with Employee G, Certified Nursing Assistant, on 09/30/2020 at 1:35 pm, she looked at the expiration dates on the cartons and stated that the dietary staff are responsible for the rotation of the nutritional supplements. She did not know why the expired cartons were still available for use in the nutrition room. Review of the employee training entitled Infection Prevention and Control: Protect Yourself, Protect Others, dated 03/2020, revealed Employees C and E were not on the sign-in list indicating they had not received the training. No other training sign in sheets were provided. Review of the facility policy and procedure entitled Hand Hygiene, #F007, last revised on 01/2020 revealed it read: In the Food & Nutrition Services Department: All associates associated with the handling of food shall wash hands. Hands are washed with soap and water at the following times: Before handling food or clean utensils/dishes/equipment. Before putting on gloves. After handling soiled silverware/utensils. After removing gloves. After any other activity that may contaminate the hands. 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 and a covered waste receptacle. Use a paper towel to turn off the faucet to avoid contact with faucet germs (Copy obtained). Review of the facility policy and procedure entitled Disposable Glove Use, #F021, last revised on 01/2020 revealed it read: Disposable, non-latex gloves must be worn at the following times: When handling ready to eat foods. When handling clean utensils/dishes/equipment. When handling soiled dishware. Procedures: Hands must be washed before putting on and after removing disposable gloves when working in the kitchen. Disposable gloves must be changed, and hands washed when the gloves are dirty or ripped and when moving from one task to another, such as moving from handling dirty dishes to handling clean dishes (Copy obtained). .

Based on observations, staff interviews, and facility document review, the facility failed to ensure the pest control service was effective. Failure to maintain a pest free kitchen allows the possibility of the spread of disease by pests and infection of the residents. The findings include: During the initial kitchen tour on 09/28/2020 from 10:33 AM until 11:25 AM, flies were observed in the kitchen and the dish room. During a follow-up tour and lunch meal service observation on 09/29/2020 from 11:35 AM until 1:37 PM, flies were again observed in the kitchen and the dish room. During an interview with the QA Specialist on 09/29/2020 at 1:10 PM, she stated that she was aware of the flies in the kitchen and she knew the pest control company had come in the last month to treat for them. She stated she thought the problem was due to a drain in the kitchen and water backing up into the kitchen, but that had been fixed. During an interview with Employee F, dish washer, on 09/29/2020 at 1:15 PM, he stated that there are many flies under the rinse sink in the dish room and it has been that way for some time now. Flies were observed to be swarming under the rinse sink in the dish room. During an interview with the contracted pest control company representative on 09/29/2020 at 1:35 PM, he stated that he had been in the facility kitchen on 09/28/2020, but was not made aware of the swarming flies in the dish room. He bent down and took his flashlight and showed this surveyor the stuck on food debris on the wall and the stainless steel chute under the rinse sink. He stated that is a good food source for the flies. He stated the standing water is also a big problem because the flies are attracted to it. Review of the facility Inspection Report dated 09/26/2020 revealed the contracted pest control company treated the facility for rats but not flies in the kitchen (Copy obtained). Review of the facility Inspection Report dated 09/25/2020 revealed the contracted pest control company noted no pest activity. The facility was treated for ants. (Copy obtained). Review of the facility Inspection Report dated 08/31/2020 revealed the contracted pest control company noted exclusion old walk-in door. Recommended exclusionary measure to inhibit pest entry. Recommended door sweep be replaced. Exposed food: Alternative food sources were noted during the inspection process. Actions: clear debris. Removal will help eliminate conductive conditions for pest activity. No pest activity noted. Cabinets under soda fountain still need to be cleaned out (Copy obtained). Review of the facility Inspection Report dated 08/28/2020 revealed the contracted pest control company noted no pest activity (Copy obtained). .