Based on observations, interviews, and policy and procedure reviews, the facility failed to maintain a clean and sanitary kitchen to prevent cross contamination and the high likelihood of foodborne illnesses to the 40 residents who ate meals prepared from the facility's kitchen. This deficient practice resulted in an Immediate Jeopardy (IJ) on 3/3/2025 at 10:35 AM when the following was observed in the facility's kitchen during the initial tour: 1. Equipment and Food Prep Area a. The ice machine's air filter had an accumulation of lint build up. b. The ice machine's gutter located under the interior portion of the lift cover had an accumulation of lint build up. c. The countertop under a juice dispenser had a dried tan colored residue. d. The standup cooler's door handle was sticky and had food residue on the plastic framing and glass door. e. The backsplash on the wall located over the food processor was splattered with dried food debris. f. The table next to the small oven had dried food debris. g. The meat slicer and shelf on which it was located had splattered food debris. h. The oven door to the right side of the stove had grease drippings down the inside of the door and onto the floor beneath. i. The inside of both oven doors contained dried food debris. j. The outside fronts of both oven doors had splattered food debris. k. The outer rim of the deep fryer and metal table on which it was located had dried food residue. l. The counter to the left of the steam table had splatter food debris. m. The lower half of the glass door to the walk in cooler contained a sticky brown substance. n. Styrofoam containers containing food were set on the countertop with a dried tan debris on the countertop. 2. Dish and Cookware Storage a. The shelf for storing cleaned dishes and a crate containing clean glasses had a white dried sediment on it. b. The top surface of the portable plate stacking rack had dried food debris on its surface. c. A 3 tiered dish shelf had a large reddish colored dried substance on the bottom shelf. 3. Flooring a. The floor on both sides and behind the stove had a sticky brown residue. b. A large number of onion peelings were scattered throughout the floor in the walk in cooler. c. A large amount of a dark colored residue on the floor in the walk in cooler d. A large area under the sink and dishwasher had dried brown and white residue. e. Food debris on the floor in the dry storage room 4. Refrigerators and Walk-in Coolers: a. The kitchen wall near the walk in cooler was splattered with dried food debris and drippings. b. There was no documentation of a temperature log for monitoring of the food contents of the free standing refrigerator. 5. Food Storage a. Refrigerated items located within the standup cooler contained food unsafe for consumption: 1. Coconut cream pie was not labeled with the date it had been opened. 2. Bottle of Catalina dressing with an expiration date of 1/29/2025. 3. Bottle of Catalina dressing with an expiration date of 2/7/2025. 4. 5 Styrofoam cups with lids that were not labeled with its contents or date it had been prepared. 5. 5 Styrofoam bowls with lids that were not labeled with its contents or date it had been prepared. 6. 2 pitchers of orange juice not labeled with the date it had been opened. 7. 1 pitcher of apple juice not labeled with the date it had been opened. 8. 1 pitcher of tea not labeled with the date it had been opened. 9. 2 plastic unlabled and undated containers covered with plastic wrap 1 contained an orange substance and 1contained a brown substance 10. 2 jars of grape jelly not labeled with the date it had been opened. 11. 1 jar of peach preserves not labeled with the date it had been opened. 12. Clear plastic container containing a salad that was not labeled with a date it had been prepared. 13. Styrofoam container containing watermelon slices that was not labeled with a date it had been opened. 14. 2 plastic containers each containing a sandwich that were not labeled with a date they were prepared. 15. 1 plastic container with brown colored contents that was not labeled with its contents or a date opened. 16. 1 quart sized plastic bag with brown colored contents that was not labeled with its contents or a date opened. 17. A plastic bin located in the walk in cooler containing cumbers. Four cucumbers had texture changes of soft spots and indentions areas which indicated the cucumbers were spoiled. 18. A package of hot dog buns had green, yellow and brownish discolorations resembling mold. 6. Sanitation a. no cleaning observed between breakfast and lunch service. S1ADM (Administrator) was notified of the IJ on 3/3/2025 at 4:30 PM. Findings: Review of the facility's policy for Food Safety Requirements, date implemented: 2/27/2025 read in part: Policy .It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state, and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety .Policy explanation and compliance Guidelines: 1 .B. Storage of food in a manner that helps prevent deterioration or contamination of the food E. Equipment used in the handling of food including dishes, mixers, and other equipment that come in contact with food .Refrigerated storage . i. Monitor food temperature of the refrigeration equipment daily . iv. Labeling, dating, and monitoring refrigerated food 6. All equipment used in the handling of food shall be cleaned 8. E. cleaning and sanitizing to the ice machine according to manufactures guidelines. On 3/3/2025 reviewed the existing cleaning schedule posted in the kitchen for evening cook and aide duties: Monday- stovetops/oven; Tuesday- freezer/cooler; Wednesday-pantry/stainless; Thursday- worktables/fryer; Friday- cooker/refrigerator; Saturday- steamtable/juice machines; Sunday- steamer/secondary steamtable. Review of the facility's Office of Public Health (OPH) Food Notice of Violation report conducted on 11/12/2024, read in part: Critical items that must be corrected immediately Food contact surfaces and utensils are not clean to sight and touch Non-critical items that should be corrected by the next regular inspections non-food contact surfaces of equipment have an accumulation of dust, dirt, food residue and other debris .floors are not clean . moist cloths used for wiping spills on food contact surfaces are not stores in approved chemical sanitizer between uses. An initial tour of the kitchen was conducted on 3/3/2025 at 10:35 AM with S2DM. The above named findings were observed. On 3/3/2025 at 10:55 AM, an interview with S2DM (Dietary Manager) and S3DA (Dietary Aide) was conducted. S3DA confirmed that the food items listed above were not labeled with the contents nor the date the food was opened or prepared. S3DA could not state whether the food was still safe to be served because she was not sure how long it had been stored in the refrigerator. S3DA further confirmed the bottles of salad dressing were expired and the hot dog buns were moldy. S2DM confirmed they were unable to provide temperature logs to the free standing refrigerator and could not verify if the food inside had been stored within the acceptable temperature range. S2DM confirmed the above issues observed during the initial kitchen tour and stated the kitchen was not clean and sanitary. On 3/3/2025 at 10:50 AM, S7PCA (Personal Care Attendant) removed an unlabeled, undated Styrofoam cup from the stand up refrigerator as she prepared salads for lunch service. When asked what she planned to use the contents of the cup for, she stated it was to be served with the salads. S7PCA acknowledged the Styrofoam cup was not labeled with its contents and she was unable to state the date it had been opened or how long it had been in the refrigerator. On 3/3/2025 at 11:15 AM, continued observations of the kitchen revealed no cleaning had been done between breakfast and lunch service as lunch service preparation was being conducted. On 3/3/2025 at 12:30 PM, during an interview with S4DC (Dietary Cook), she stated a cleaning schedule posted for staff to follow so they would know what was scheduled to be cleaned for the day. She observed the condition of the kitchen and acknowledged the kitchen was not clean and sanitary. On 3/3/2025 at 1:00 PM, during an interview with S2DM, she reviewed the cleaning schedule of the kitchen and stated that staff were to clean according to the schedule at the end of each day prior to staff leaving for the day. She stated she was responsible for overseeing the kitchen and acknowledged she failed to monitor the kitchen to ensure its cleanliness. S2DM was unable to provide information on when the last time the tasks on cleaning schedule had been completed. On 3/3/2025 at 1:15 PM, an observation of the kitchen and interview was conducted with S1ADM. He stated dietary staff should conduct a cleaning of the kitchen daily and that S2DM was responsible for overseeing kitchen operations. He acknowledged he was ultimately responsible for the kitchen and confirmed he observed that the kitchen was not sanitary. On 3/3/2025 at 2:30 PM, an interview with conducted with S5DON (Director of Nursing). She confirmed she was the facility's Infection Preventionist. She stated that on 2/27/2025, she conducted a walkthrough of the kitchen and noticed that floors in the kitchen had debris and needed to be cleaned. She acknowledged that the unsanitary conditions of the kitchen could put residents at risk for foodborne illnesses. On 3/5/2025 at 1:25 PM, a telephone interview was conducted with S6RD (Registered Dietician). She stated she was the consultant dietician for the facility and that S2DM was responsible for overseeing the kitchen. S6RD confirmed the kitchen should be clean, sanitary, and that the food should be stored safely to ensure food served is safe for consumption. The IJ was removed on 3/4/2025 at 2:30 PM when the facility presented an acceptable Plan of Removal (POR). Through observations, interviews and record review, the surveyors confirmed the following components of the POR had been initiated and/or implemented prior to exit. The POR, read: A. Identification of those who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: 40 residents have the potential to be affected by this deficient practice. No evidence of food related GI (Gastrointestinal) illness were noted at this time. Any negative findings moving forward will be reported to the Medical Director immediately. B. Actions the facility will take: The dietary manager, as well as dietary staff, were interviewed on 3/3/2025 at 3:05 PM and determined to have insufficient knowledge of regulations and sanitation processes. Dietary policy and procedures regarding food storage, sanitation, cleaning schedules of the kitchen and appliances, and temperature checks were reviewed. The dietary manager, as well as other present dietary staff, were in-serviced on the facility's policy and procedures along with a pre/posttest to ensure sufficient understanding. This was initiated on 3/3/2025 at 3:05 PM and will be ongoing. All remaining dietary staff will be trained/in-serviced prior to the start of their work shift. Administrator will set up an education in-service with the registered dietician. The registered dietician will round and audit kitchen area twice monthly for 3 months, then resume monthly thereafter. May extend this time as the administrator sees fit. The administrator will round in the kitchen daily beginning 3/3/2025 until compliance is met. Upon notification of the deficit practice and the closure of kitchen, supper was prepared and provided for residents from the facility's sister facility. Arrangements have been made for all meals to be prepared and provided by the sister facility until the re-opening of this facility's kitchen. AII meals will be served from the secondary steam table located outside the main kitchen area, which remains in compliance. The sanitation process in the kitchen began immediately on 3/3/2025 at 1:30 PM. corporate staff was called in to assist with the process. Immediately upon notification, staff implemented an intense cleaning of the kitchen. Molded bread and vegetables were discarded. All unlabeled and expired refrigerated foods were discarded. AII other items checked and were noted to be labelled and dated. This was completed on 3/3/2025 by 4:45 PM. C. Education I Training Plan: AII dietary staff have the potential to be impacted by the noncompliance. Current dietary staff working in house on 3/3/2025 were in-serviced verbally on policies in regard to the kitchen hood inspection and cleaning, maintaining a sanitary tray line, Food Safety requirements, sanitation inspection, cleaning schedules of the kitchen and appliances, and temperature checks as well as temperatures for safe food handling on 3/3/2025 at 3:05 PM. The education provided on 3/3/2025 was done by the regional Registered Nurse. A pre/posttest made per Administrator and it will be utilized with continued education to ensure understanding with the dietary staff. This will begin on 3/4/2025. A Dietary Sanitation Orientation checklist will be completed with all dietary staff that are currently employed beginning 3/4/2025, and will be added to new hire packets. D. Monitoring of Implemented Action(s): Register dietician will be scheduled to make sanitation rounds at the facility twice monthly until compliance is met. May be extended as administrator sees necessary. Moving forward, effective 3/4/2025, Administrator will round in the kitchen 5 days per week to ensure compliance is met. This will continue daily for 2 weeks, then once weekly thereafter. To be monitored daily by administrator: Sanitary storage and safety, refrigerator and freezer are clean, work area is clean, major equipment and utensils are clean, storage area is clean, foods are covered, labeled and dated, food and non-food supplies are separated, trash containers are clean and covered, food is being stored off the floor, proper scoop storage, cleaning scheduled is posted, utility area for mop storage is clean, dishwashing area is clean, dishes are without stains and residue, proper wash/rinse temperatures, pots and pans surfaces are clean, personal hygiene of staff, hair restraints used, personal items stored properly, and proper hand washing techniques. If further non-compliance is noted, disciplinary actions will be taken as administrator sees fit. This plan will be implemented into the facility QAPI process and reviewed with IDT (Interdisciplinary Team) at meetings. This will be put into a QAPI process on 3/4/2025. A cleaning schedule will be implemented as followed: Monday- stove top, oven deep clean; Tuesday- freezer, cooler, freezer door; Wednesday- pantry, stainless/dish room; Thursday- work tables, fryer; Friday- cooler, clean refrigerator guard; Saturday- steam tables, clean all juice machines; Sunday- steamer, steamtable at secondary location. A master cleaning schedule will be implemented with areas to be cleaned along with frequency: extractor hood- general- once weekly; extractor hood filters and grease traps- once weekly; oven to be wiped down daily; Flat top- wipe down daily; Grill- daily; Cookers/burners- 4 time per week; Oil Fryer- wipe down daily; Legs and supports to equipment- 4 days per week; Gas pipes and taps- 3 times per week; Warmer- 3 times per week; Cleaning equipment (mops, buckets, cloths, brushes, etc.) -cleaned daily; Refuse areas: Floors- daily; doors- twice weekly; and walls- twice weekly.