DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES KITCHEN/FOOD SERVICE OBSERVATION Facility Name: Provider Number: Observation Dates/Times: Surveyor Name: Surveyor Number:_____________ Discipline: Instructions: Use the questions below to focus your observations of the kitchen and the facility's storage, preparation, distribution and service of food to residents. Initial that there are no identifiable concerns or note concerns and follow-up in the space provided. All questions relate to the requirement to prevent the contamination of food and the spread of food-born illness. LIST ANY POTENTIAL CONCERNS FROM OFFSITE SURVEY PREPARATION:______________ ___________________________________________________________________________________ FOOD STORAGE 1. Are the refrigerator and freezer shelves and floors clean and free of spillage, and foods free of slime and mold? 2. Is the refrigerator temperature 41 degrees F or below (allow 2-3 degrees variance) and are foods in the freezer frozen solid? Do not check during meal preparation.. 3. Are refrigerated foods covered, dated, labeled, and shelved to allow air circulation? 5. Is dry storage maintained in a manner to prevent rodent/pest infestation? 4. Are foods stored correctly (e.g., cooked foods over raw meat in refrigerator, egg and egg rich foods refrigerated)? FOOD PREPARATION 6. Are unpasteurized eggs being used only in foods that are thoroughly cooked, such as baked goods or casseroles? 7. Are frozen raw meats and poultry thawed in the refrigerator, microwave as a part of the cooking process, or submerged under cold, running water? Are cooked foods cooled down safely? 8. Are food contact surfaces and utensils cleaned to prevent cross-contamination and food-borne illness? FOOD SERVICE/SANITATION 10. Are food trays, dinnerware, and utensils clean and in good condition? 9. Are hot foods maintained at 135 degrees F or above and cold foods maintained at 41 degrees F or below when served from tray line? 12. Are employees practicing appropriate hand hygiene while preparing food, wearing gloves or using clean utensils to handle ready-to-eat food and following infection control practices? 11. Are the foods covered until served? Is food protected from contamination during transportation and distribution? 13. Are food preparation equipment, dishes and utensils effectively sanitized to destroy potential food borne illness? Is dishwasher's hot water wash 140 degrees F and rinse cycle 180 degrees F or chemical sanitation per manufacturer's instructions followed to achieve effective washing and sanitizing? 14. Is facility following correct manual dishwashing procedures (i.e., 3 compartment sink, correct water temperature, chemical concentration, and immersion time)? NOTE: If any nutritional concerns have been identified for a resident, (such as weight loss) by observation, interviews or 1/4 C = 2 oz., 1/2 C = 4 oz., 3/4 C = 6 oz., 1 C = 8 oz. LADLES: SCOOPS: #6 = 2/3 C., #8 = 1/2 C., #10 = 2/5 C., #12 = 1/3 C., #16 = 1/4 C. record review; Review further to determine appropriate food, nutrition, and dietary services were provided to meet the needs of the residents. THERE ARE NO IDENTIFIED CONCERNS FOR THESE REQUIREMENTS: (Init.) ____ Document concerns and follow-up on back of page. Form CMS-804 (06/16) American LegalNet, Inc. www.FormsWorkFlow.com KITCHEN/FOOD SERVICE OBSERVATION Tag/Concerns Source* Surveyor Notes (including date/time) *Source: O = Observation, RR = Record Review, I = Interview Form CMS-804 (06/16) American LegalNet, Inc. www.FormsWorkFlow.com