DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Kitchen/Food Service Observation
Facility Name:
Facility ID:
Date:
Surveyor Name:
Complete the initial brief kitchen tour upon arrival at the facility, with observations focused on practices that might indicate potential for food borne
illness.
Make additional observations throughout the survey process in order to gather all information needed.
Mark any areas of concern identified under each General Category (e.g., Storage Temperatures, Food Storage, etc.).
Initial Brief Tour of the Kitchen
Notes
The intent of this initial brief tour is to identify any practices that might indicate potential for
food borne illness. Observations during this tour may also help identify additional areas of
concern listed on this worksheet.
Observe for:
Potentially hazardous foods, such as beef, chicken, pork, etc., thawing at room temperature;
Food items in the refrigerator(s) that are unlabeled or undated and not scheduled to be served
at the next meal;
Potentially hazardous foods like uncooked meat, poultry, fish, and eggs that are not stored
separately from other foods (e.g., meat is thawing so that juices are dripping on other foods);
and
Appropriate hand washing facilities with soap and water that are not convenient for dietary
staff use.
1. Are foods stored under sanitary conditions? Yes No F371
FORM CMS–20055 (9/2014)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Kitchen/Food Service Observation
Initial Brief Tour of the Kitchen
Notes
Observe for:
Staff not practicing hand washing when necessary during food preparation activities;
Cracked or unpasteurized eggs that are used in foods that are not fully cooked (per
observation or interview);
Food that is not prepared, cooked, or stored under appropriate temperatures and with safe
food handling techniques;
Staff not washing hands to prevent cross contamination (e.g., between handling raw meat and
other foods); and
Staff not utilizing hygienic practices (e.g., touches hair, face, nose) and then handles food).
2. Does the facility prohibit staff with open areas on their skin, signs of infection, or other
indications of illness, from handling food products? Yes No F441
3. Are foods prepared under sanitary conditions? Yes No F371
NA, food was not being prepared during the Initial Tour.
If staff are preparing food: Proceed with observations. If not, answer the remaining items in
future trips to the kitchen (see related sections below).
FORM CMS–20055 (9/2014) 2
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Kitchen/Food Service Observation
Follow-up Visit(s) to the Kitchen
Notes
Storage Temperatures
Observe for:
Refrigerator temperatures that are at or below 41 degrees Fahrenheit (°F) (check temperatures
between meal service activities to allow for stable temperatures).
*
Freezer temperatures maintained at a level to keep frozen food solid.
Internal temperatures of potentially hazardous, refrigerated foods (e.g., meat, fish, milk, egg,
poultry dishes) that are not within acceptable ranges of 41°F or lower:
What are the temperatures?
What foods are involved?
*
Cited food temperatures are target temperatures from the current FDA Food Code.
4. Is the food stored at the appropriate temperatures? Yes No F371
FORM CMS–20055 (9/2014) 3
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Kitchen/Food Service Observation
Follow-up Visit(s) to the Kitchen
Notes
Food Storage
Observe for:
Frozen foods thawing at room temperature;
Foods in the refrigerator/freezer that are not covered, dated, and shelved to allow circulation;
Foods stored in direct contact with soiled surfaces or rust;
Canned goods with a compromised seal (e.g., punctures);
Staff touching food when accessing bulk foods;
Containers of food stored on the floor or on surfaces that are not clean;
Signs of water damage from sewage lines and/or pipelines;
Signs of negative outcome (i.e., freezer burn, foods dried out, foods with a change in color);
Raw meat stored so that juices are dripping onto other foods; and
The facility’s policy for food storage, including leftovers. Does staff follow the policy?
5. Are foods stored under sanitary conditions? Yes No F371
FORM CMS–20055 (9/2014) 4
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Kitchen/Food Service Observation
Follow-up Visit(s) to the Kitchen
Notes
Food Preparation and Service
Observe for:
Hot foods not held at 135°F or higher on the steam table;*
Cold foods that are not held at 41°F or lower;*
Food surfaces that are not thoroughly cleaned after preparation of fish, meat, or fowl:
Cutting surfaces that are not sanitized between uses;
If staff is preparing resident requests for soft cooked and undercooked eggs (i.e. sunny side up,
soft scrambled, soft boiled), determine if pasteurized shell eggs, liquid pasteurized eggs or
unpasteurized shell eggs were used;
Improper final internal cooking temperatures (monitoring the food’s internal temperature for
15 seconds determines when microorganisms can no longer survive and food is safe for
consumption). Foods should reach the following internal temperatures:
Poultry and stuffed foods: 165°F;
Ground meat (e.g., ground beef, ground pork), ground fish, and eggs held for service: at
least 155°F;
Fish and other meats: 145°F for 15 seconds;
When cooking raw animal foods in the microwave, foods should be rotated and stirred
during the cooking process so that all parts of the food are heated to a temperature of at
least 165°F, and allowed to stand covered for at least 2 minutes after cooking to obtain
temperature equilibrium; and
Fresh, frozen, or canned fruits and vegetables: cooked to a hot holding temperature of
135°F to prevent the growth of pathogenic bacteria that may be present.
Food items that are not reheated to the proper temperatures:
The PHF/TCS food that is cooked and cooled must be reheated so that all parts of the
food reach an internal temperature of 165°F for at least 15 seconds before holding for hot
service.
Ready-to-eat foods that require heating before consumption are best taken directly from a
sealed container (secured against the entry of microorganisms) or an intact package from
FORM CMS–20055 (9/2014) 5
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Kitchen/Food Service Observation
Follow-up Visit(s) to the Kitchen
Notes
Food Preparation and Service
Food that is not covered during transportation and distribution to residents;
Food that is not cooked in a manner to conserve nutritive value, flavor, appearance and
texture;
Nourishments and snacks held at room temperature and not served within 4 hours of delivery.
Potentially hazardous foods (e.g., milk, milk products, eggs) must be held at appropriate
temperatures;
Staff that do not properly wash hands with soap and water to prevent cross contamination
(i.e., between handling raw meat and other foods);
Staff who does not utilize hygienic practices (e.g., not touch hair, face, nose, etc.) and then
handle food);
Staff who serve food to residents after collecting soiled plates and food waste, without proper
hand washing;
Leftovers that are not cooled quickly and promptly in shallow pans in the refrigerator or
freezer;
Potentially hazardous foods that are not cooled from 135°F to 70°F within 2 hours; from
70°F to 41°F within 4 hours; the total time for cooling from 135°F to 41°F should not exceed
six hours;*
Food that is not procured from vendors that meet federal, state, or local approval;
If there is an outbreak of food borne illness and the facility’s primary food service has been
ruled out as the cause of the outbreak, review the policies and procedures for maintaining
nursing home gardens, if applicable.
The time food is put on the steam table and when meal service starts. If unable to observe,
determine per interview with the cook;
How staff routinely monitors food temperatures on the steam table (review temperature logs);
When staff starts cooking the food. If unable to observe, determine per interview with the
cook;
What cooking methods are available and used (e.g., steamer, batch-style cooking); and
FORM CMS–20055 (9/2014) 6
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Kitchen/Food Service Observation
Follow-up Visit(s) to the Kitchen
Notes
Food Preparation and Service
Ask staff:
Are you aware of current CDC and FDA nursing home egg handling and preparation
policies?
Does the facility have written egg storage and preparation policies that honor resident
preferences safely?
If a food borne illness outbreak occurred: Did you report the outbreak to the local health
department?
*
See F371. Cited food temperatures are target temperatures from the current FDA Food Code.
6. Does the facility prohibit staff with open areas on their skin, signs of infection or other
indications of illness, from handling food products? Yes No F441
7. Does the facility provide food prepared by methods that conserve nutritive value,
flavor, and appearance and that is palatable, attractive, and at the proper temperature?
Yes No F364
8. Was food procured from approved or satisfactory sources and stored, prepared, and
served under sanitary conditions? Yes No F371
FORM CMS–20055 (9/2014) 7
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Kitchen/Food Service Observation
Follow-up Visit(s) to the Kitchen
Notes
Dinnerware Sanitization and Storage
Observe for:
Dishwasher temperatures that are not at 150°F wash, 180°F rinse OR 120°F wash + 50 ppm
(parts per million) Hypochlorite;
The manual method – After washing and rinsing, dishes are sanitized by immersion in either:
Hot water (at least 171°F) for 30 seconds; or
A chemical sanitizing solution. If explicit manufacturer instructions are not provided, the
recommended sanitation concentrations are as follows:
− Chlorine: 50 – 100 ppm minimum 10 second contact time
− Iodine: 12.5 ppm minimum 30 second contact time
− QAC space (Quaternary): 150 – 200 ppm concentration and contact time per
manufacturer’s instructions (Ammonium Compound)
Dishes, food preparation equipment, and utensils that are towel dried. (Drying food
preparation equipment and utensils with a towel or cloth may increase risks for cross
contamination.);
Clean and soiled work areas that are not separated; and
Dishware that is not stored to prevent contamination. (In a clean, dry location, not exposed to
splash, dust, or other contamination and covered or inverted.)
Ask staff:
How do they test for proper chemical sanitization (observe them performing the test)?
How do they monitor equipment to ensure that it is functioning properly? (Review
temperature/chemical logs.)
9. Were dishes and utensils cleaned and stored under sanitary conditions?
Yes No F371
FORM CMS–20055 (9/2014) 8
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Kitchen/Food Service Observation
Follow-up Visit(s) to the Kitchen
Notes
Equipment Safe/Clean
Observe for:
Refrigerators and freezers that are not clean and in safe operating condition;
Fans in food prep areas that are not clean;
Utensils/equipment that are not cleaned and maintained to prevent food borne illness;
Food trays, dinnerware, and utensils that are not clean and in good condition (e.g., not
cracked or chipped, etc.); and
Lack of appropriate equipment and supplies to evaluate the safe operation of the dish
machine and the washing of pots and pans (e.g., maximum registering thermometer,
appropriate chemical test strips, and paper thermometers).
Ask staff:
What is the facility’s practice for dealing with employees who come to work with symptoms
of contagious illness (e.g., coughing, sneezing, diarrhea, vomiting) or open wounds;
How does the facility identify problems with time and temperature control of PHF/TCS foods
and what are the processes to address those problems;
Whether the facility has, and follows, a cleaning schedule for the kitchen and food service
equipment; and
If there is a problem with equipment, how staff informs maintenance and follows up to see if
the problem is corrected.
10. Is the food preparation equipment clean? Yes No F371
11. Is essential kitchen equipment maintained in safe operating condition?
Yes No F456
FORM CMS–20055 (9/2014) 9
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Kitchen/Food Service Observation
Follow-up Visit(s) to the Kitchen
Notes
Refuse/Pest Control
12. Was garbage and refuse disposed of properly? Yes No F372
13. Are food storage, preparation, and service areas free of visible signs
of insects and/or rodents? Yes No F469
If Question 12 or 13 is marked ‘No’:
Is there documentation of pest control services that have been provided?
Is the facility aware of the current problem?
If the facility is aware of the current problem, what steps have been taken to eradicate the
problem?
Notify team of observations and review other areas of the environment for pest concerns.
Follow-up Visit(s) to the Unit
Notes
14. Are snack/nourishment refrigerators on the unit maintained so as to prevent the
potential for food-borne illness Yes No F371
15. Are proper refrigerator (snack/nourishment) temperatures maintained and are food
items dated/labeled? Yes No F371
FORM CMS–20055 (9/2014) 10