§483.60(i) Food safety requirements.
The facility must -
§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.
§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
|
Observations:
Based on observations, review of facility policy, and staff interview, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the kitchen.
Findings include:
Review of facility policy, titled Personal Hygiene, revised January 2026, read, in part, cover facial hair with a beard guard, nails trimmed and clean with unpolished fingernails.
Review of facility policy, titled Dress Code, not date marked, read, in part, disposable gloves are single use and changed between tasks.
Observations on February 9, 2026, in the kitchen revealed the following:
At 11:16 AM, Employee 2 (Food Service Director) was preparing food for the lunch meal, removed her gloves, utilized a cell phone, donned fresh gloves without completing hand hygiene and returned to preparing food. At that time Employee 2's fingernails were one inch long and contained nail polish.
At 11:20 AM, Employee 1 (Dietary Aide) had a full beard and was walking through the kitchen without a beard covering.
At 11:30 AM, Employee 3 (Dietary Aide) was wearing gloves, retrieved a # 10 can (3 quarts) of chocolate pudding from the storage rack; with the same gloved hand dished a portion of salad into a bowl; then proceeded to open the reach-in refrigerator; then the walk-in refrigerator; touched her face, hair, pants and sweater; opened a bag of grated cheese and touched cheese with the same gloved hand to transfer it to a container, and then topped the salad in the bowl with the cheese. Employee 3 didn't change gloves or complete hand hygiene.
At 11:35 AM, Employee 4 (Dietary Aide) with gloved hands emptied a bag of lettuce on top of the lettuce already in a large metal bow; moved a cardboard box from the counter to the floor; opened a bag of red shredded cabbage and emptied it into the bowl of lettuce and tossed it with the lettuce; and portioned the lettuce out into bowls with the same gloved hands. Employee 4 didn't change gloves or complete hand hygiene.
At 11:40 AM Employee 5 (Cook) with gloved hands opened frozen cauliflower, placed it into a steamtable pan; using a hot pad retrieved chicken from the oven; using the same gloved hand topped the chicken with grated cheese; delivered the pan of chicken to the steam table. Employee 5 didn't change gloves or complete hand hygiene.
At 11:55 AM Employee 6 (Dietary Aide) with gloved hands operated the elevator (touching buttons, the door and security fence), and with the same gloved hand retrieved two crustless grilled cheese sandwiches from the food warmer and placed the sandwiches on a plate on the tray line. Employee 6 didn't change gloves or complete hand hygiene.
Interview with the Nursing Home Administrator (NHA) and Assistant NHA on February 10, 2026, at 3:00 PM, it was revealed they were made aware of a social media post from a former Dietary Aide documenting concerns with hand hygiene, hair coverings, and other food sanitation concerns at the facility. The consultant Food Service Company completed training on hand hygiene and use of hair coverings the week prior. It was revealed that the facility training personnel would be completing additional training with the Dietary Department.
28 Pa code 211.6(f) - Dietary Services
| | Plan of Correction - To be completed: 03/05/2026
This provided submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.
1. Employee 2, Employee 1, Employee 3, Employee 4, Employee 5 and Employee 6 were educated on the following: Hand Hygiene in regards to handwashing, Hand Hygiene in regards to gloving and de-gloving, Wearing hair and beard covers in the kitchen and having appropriate nail length free of nail polish.
2. To identify other staff that have the potential to be affected, the NHA/designee conducted an observational audit in the kitchen to ensure staff are practicing hand hygiene, proper gloving and de-gloving during tasks, wearing beard and hair covers and have appropriate nail length free of nail polish. Observational audit continued for 2x a day for 7 days for 1 week.
3. Dietary staff were educated on proper nail length free of nail polish, hand hygiene in regards to gloving and de-gloving as well as hand washing and changing gloves between tasks and wearing beard and hair covers in the kitchen.
4. The NHA/designee will conduct an observational audit 1x a day for 5 days a week for 8 weeks in the kitchen to ensure staff are practicing hand hygiene, proper gloving and de-gloving during tasks, wearing beard and hair covers and have appropriate nail length free of nail polish. Results of the audits will be reviewed at the QAPI meeting to determine if future action/audits are needed.
|
|
