St Johns Health Care Corporation
May 9, 2017 Complaint Survey

Standard Health Citations


REGULATION: (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. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 9, 2017
Corrected date: May 30, 2017

Citation Details

Based on observations and interviews conducted during an Abbreviated Survey (complaint #NY 111) completed on 5/9/17, it was determined that for one of one Bistro Cafeteria, the facility did not store or serve food under sanitary conditions. The issue involved lack of proper labeling on ready to serve food products in the Bistro 150 Cafeteria. This is evidenced by the following: During an observation on 5/8/17 at 5:00 p.m., there were five residents eating in the Bistro 150 Cafeteria. The Bistro Cafeteria Grab and Go refrigerated shelving unit contained the following undated food items: a. Three fruit salads with strawberries, pineapple, cantaloupe, honeydew melon and either yogurt or cottage cheese. b. Three packages of wraps, two with ham and swiss cheese and one with turkey and provolone cheese. c. Three salads with bacon, turkey and cheese. d. Two tapioca puddings with whipped cream. e. Two butterscotch puddings with whipped cream f. Three slices of cherry cake with frosting. g. Two fruit cups with blueberries, honeydew and cantaloupe melons, and pineapple. When interviewed at that time, the Assistant Manager of Dining Services said the food in the Bistro 150 Cafeteria is mostly for staff but residents and families can eat there, too. She said at the end of the service, any food that is left is stored in the back cooler. She said the food is kept for two days. She said if the food items are undated, she does not know how staff would determine when to discard the items. During an interview on 5/9/17 at 10:45 a.m., the Dining Manager (DM) said that all food items should be dated, including items in the Bistro Cafeteria Grab and Go. He said staff are trained to date all foods and keep foods for three days. At that time, the surveyor and DM observed the cafeteria refrigerator unit which contained undated fruit cups, salads, wraps and puddings. The DM said that at the end of the evening shift the wraps are discarded but the other foods are put into the cooler in the kitchen. He said the staff would not know when to discard undated foods. The DM said that the kitchen staff prepare the food packages and store them in the kitchen cooler. He said that the cafeteria staff then pull the food items for cafeteria use. He said the food items are available during the day so any resident could come down to eat. The DM said that there are five regular residents that almost always eat in the cafeteria. Review of the undated facility policy, Standards of Practice for Labeling, Dating, and Discarding of Food, documented that foods must be date-marked if they are not to be used within 24 hours of preparation. (10 NYCRR 415.14(h); 14-1.43(e))

Plan of Correction: ApprovedMay 25, 2017

All the food items that were identified as undated (3 fruit salads. 3 wraps, 3 salads, 2 tapioca puddings, 2 butterscotch puddings, 3 slices of cherry cake, and 2 fruit cups) were immediately discarded. (Dining Services Manager, 5/9/17)
An audit of café food occurred including Grab and Go cooler to monitor that these labels are being used and food is being discarded in a timely fashion. (Dining services manager, 5/30/17)

Audits on café food will occur weekly for 3 weeks and frequency reviewed after a QAPI review on 5/30/17 and compliance with no outdated food in the ?Grab and Go? cooler and that all food is properly labeled and dated according to policy.
All the labels for products served in our Grab and Go and in the café will include a ?created on? date and then a ?use by? date. The ?use by? date is 3 days following the ?created on? date. We have in-serviced dining staff on the Food storage policy, labeling changes, and they have signed a log sheet. (Dining Practice partner, 5/30/17)

Audit results will be reviewed weekly by the Dining Practice Partner and Dining Manager to assure compliance. The results of the audit will also be shared at the monthly QAPI meeting (Dining Practice partner 5/30/17, 8/17, 11/17)