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Based on observation, review and interview the facility failed to:

A. ensure the Quality Assurance Performance Improvement (QAPI) program recognized, developed and implemented performance improvements projects to address the safe handling of food in the dietary department.

Potential areas for cross-contamination due to unsanitary food handling, unsanitary cooking implement storage, unsanitary food service items (pots, pans, bowls, and plates) storage, and poor general sanitation practices was found throughout the dietary department.


Refer to tag A0297 for additional information.

Based on observation, review and interview the Quality Assurance Performance Improvement (QAPI) failed to recognize, develop and implement performance improvements projects to address the safe handling of food in the dietary department.

Findings include:

A tour was taken in the kitchen on 4/25/17 after 10:00 AM, with staff #1, 3, 4, 9, 16, 17, 18, and 19 . Some of the following were found:


The warming oven had three pans of spinach and mushrooms mixture. One of the pans was not dated. On the bottom of the warming oven was a large pot of a inidentifiable red liquid sauce. There was no date on the sauce.


A vegetable/salad prep table w/refrigerated base unit was located in the center of the kitchen across from the grill. In the top of the refrigerated box was salad type items stored in bins. In the top drawers on the right side, vegetables were found in containers. The refrigerated drawer gasket was broken and hanging down. The drawer was not properly sealed. In the bottom drawer was three pans of meat. Half of the meat was covered in plastic the other half was exposed. The meat did not have a date on it. The middle pan of meat looked gray. The drawer had a broken gasket and was not sealing properly. In the left bottom drawer a pan of catfish was found defrosted and covered with plastic wrap. The fish had a strong pungent smell and there was no date on the fish. The drawer gasket was broken and soiled with food particles.

There was only one thermometer in the top of the unit under some hard boiled eggs. The temperature of the unit was 42 degrees, 2 degrees out of range (range 40F or below).These meats stored in the unit were not on the main menu to be served. The chef was unable to state when the meat was placed in the refrigerated units for use. The chef stated these were meats used as an alternative meal if the patient did not like what was on the daily menu. The chef threw the meats away.

Across from the grill was a prep table with a freezer drawer. The drawer had an open bag of frozen French fries, hamburger patties and breaded chicken. There were no dates on when the bags were opened and how long those items were in the drawer.

During the previous survey with an exit date of 03/02/2017 seven containers of food were found in the warmer with no dates of preparation.


On 4/25/17, twenty wrought iron chairs in the dining area were missing paint.

During the previous survey with an exit date of 03/02/2017 the metal chairs in the dining room were missing paint and soiled with dried food particles, liquid and dust.

On 4/25/17, ten pans were found stored wet and had to be removed.

During the previous survey with an exit date of 03/02/2017 fourteen pots and pans were put up wet on the shelf.


On 4/25/17, The salad bar line had a display holding 5 bottles of oils and vinegars. The bottles had been opened and they were half full. The bottles were soiled and greasy to touch. There was multiple fingerprints on the bottles with no dates of opening found. The chef reported the bottles had been there for a long time and he was not sure when they were first opened.

During the previous survey with an exit date of 03/02/2017, two gallon containers of salad dressing was found with no open dates.

On 4/25/17, Open buckets of cleaning solutions were found around food preparation tables with food out and exposed to chemicals.

During the previous survey with an exit date of 03/02/2017, cleaning liquids were found in open containers on the food prep table while food was being prepared.

The deficient practices identified during the survey with an exit date of 03/02/2017 were not corrected. The same deficient practices were found during the survey with an exit date of 04/25/2017.

Review of the Quality Council Meeting dated 3/15/17 concerning the Dietary Department revealed the only issues brought to QAPI were meal timeliness.

An interview with staff #4 on 4/25/17 revealed the QAPI department had no improvement projects for the issues listed above from the survey with an exit date of 03/02/2017.