Deficiencies in Kitchen Maintenance and Food Safety Standards
Penalty
Summary
The facility was found to have deficiencies in the storage, preparation, distribution, and serving of food in accordance with professional standards for food service safety. During an observation of the Main Kitchen, it was noted that the ceiling was covered in a layer of dark gray dust, affecting the ceiling tiles, grid, vents, sprinkler heads, and heat detectors. The Director of Dining Services acknowledged that the ceilings were not cleaned by the Dietary staff and should have been addressed by the Maintenance staff. However, a maintenance work order was not submitted, and the issue was not communicated to the current Maintenance staff after the former Director of Maintenance left the facility. Additionally, inspection reports from an outside contractor indicated that the heat detectors in the kitchen were dirty, with one detector being caked in dust and needing relocation. Further observations revealed a damaged wall behind the extinguishment hood in the Main Kitchen, with chipped and cracked paint and drywall paper peeled. The Director of Dining Services confirmed that the wall required repair and that clean dishes were stored against it. Interviews with the Director of Facilities Maintenance and the Administrator indicated that kitchen cleaning responsibilities were divided between Dietary and Maintenance staff, with deep cleaning and repairs needing to be scheduled during off-hours. Despite being aware of the issues for several months, the Director of Dining Services and the Administrator did not ensure that the necessary maintenance work was completed, leading to the continued presence of these deficiencies.
Plan Of Correction
Plan of Correction: Approved February 13, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? All areas of the kitchen were thoroughly cleaned, including walls and ceilings. The areas specifically mentioned as deficient were resolved; the ceiling tile grid, the vents, sprinkler heads, and heat detectors were cleaned prior to the conclusion of the annual survey. The wall areas noted to be damaged have been repaired. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be impacted by this deficient practice. The cleanliness of the kitchen will be monitored by the director of dining services. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? A cleaning schedule will be developed collaboratively between the director of dining services and the director of maintenance to maintain cleanliness of the kitchen, specifically the ceiling which would be difficult for dietary staff to maintain. The ceiling tiles, sprinkler heads, vents, and heat detectors will be cleaned on a monthly basis and as needed to maintain the sanitary conditions of the kitchen. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? The Director of Dining Services will complete environmental audits monthly for 3 months to identify any dust-laden ceilings or damaged walls. Results of all audits will be submitted to the QA committee for review and results will be reviewed monthly. The administrator will be responsible for overseeing the completion of this plan of correction and will be completed on (MONTH) 12, 2025.