Form Cms-804 - Kitchen/food Service Observation

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
KITCHEN/FOOD SERVICE OBSERVATION
Facility Name:
Surveyor Name:
Provider Number:
Surveyor Number:_____________ Discipline:
Observation Dates/Times:
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?
4. Are foods stored correctly (e.g., cooked foods over raw meat in refrigerator, egg and egg rich foods refrigerated)?
5. Is dry storage maintained in a manner to prevent rodent/pest infestation?
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
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?
10. Are food trays, dinnerware, and utensils clean and in good condition?
11. Are the foods covered until served? Is food protected from contamination during transportation and distribution?
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?
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
record review; Review further to determine appropriate food, nutrition, and dietary services were provided to meet
the needs of the residents.
LADLES:
/
C = 2 oz.,
/
C = 4 oz.,
/
C = 6 oz., 1 C = 8 oz.
1
1
3
4
2
4
SCOOPS: #6 =
/
C., #8 =
/
C., #10 =
/
C., #12 =
/
C., #16 =
/
C.
2
1
2
1
1
3
2
5
3
4
THERE ARE NO IDENTIFIED CONCERNS FOR THESE REQUIREMENTS: (Init.) ____
Document concerns and follow-up on back of page.
Form CMS-804 (06/16)

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