Sanitation Deficiencies in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the kitchen and nourishment rooms, as evidenced by multiple observations during a survey. A milky, brown liquid with solid particles was found on the floor behind the ice machine, and debris was observed under the dry storage shelf. A green film was noted in the walk-in refrigerator, and the pipes under the three-compartment sink were dirty and leaking, with a bucket collecting grey water underneath. Additionally, food-like debris and a white film were found on the fryer basket, and a thick grease-like coating was observed on the pipes and valves behind the stove. In the nourishment room, coffee ground-sized debris and dried food residue were present, and black and green debris were found under the sink in the memory care unit nourishment room. Interviews with staff revealed a lack of awareness and action regarding these issues. The Maintenance Director acknowledged that housekeeping staff should clean behind the microwave and under cabinets but was unable to identify the debris. The Director of Nursing also could not identify the debris and attempted to clean it with bleach wipes. The Dietary Manager admitted that the kitchen staff was responsible for cleaning but did not know what the debris was and acknowledged the leaking sink pipe without having submitted a work order for repair. Housekeeping staff mentioned that there was no checklist for cleaning tasks, indicating a lack of structured cleaning protocols.
Plan Of Correction
1. All identified areas (kitchen floor, behind/under equipment, walk-in refrigerator, and nourishment rooms) were immediately addressed and cleaned on. Deep cleaning on all the affected areas conducted through. The leaking triple sink pipe was repaired on, and the area sanitized. Debris and residue in both nourishment rooms were cleaned and sanitized using EPA-registered bleach wipes or appropriate sanitizing agents were made available in nourishment rooms for as-needed cleaning. 2. A comprehensive inspection of the kitchen and all nourishment rooms was conducted on by DON, Environmental Services, and the Dietary Manager. No evidence of foodborne illness or resident harm was identified. All other high-risk food prep and storage areas were assessed for cleanliness and sanitation. 3. A detailed cleaning checklist was created and implemented for daily and weekly tasks in both kitchen and nourishment areas. It includes behind/under equipment, baseboards, and cabinet surfaces. A Deep Cleaning Schedule was established for all food service and nourishment areas and posted in each department. TELS electronic work order system was re-trained with staff to ensure all maintenance issues (e.g., leaks) are reported immediately. Daily sanitation logs are now completed by dietary and housekeeping and reviewed by the Department Heads. The Dietary Manager and Environmental Services must perform and document weekly walk-throughs using a standardized sanitation audit tool. Housekeeping and dietary staff received re-education on: - Facility policy "Cleaning and Control Standards for Environmental Surfaces" - Proper cleaning procedures, frequencies, and escalation of maintenance issues. 4. The QA Committee will review sanitation reports monthly for 4 months and adjust procedures as needed. Random monthly audits will be conducted by the Preventionist or Designee using the sanitation audit tool. Any issues found will trigger immediate re-cleaning, retraining, and documentation. Continued compliance will be tracked and reported quarterly during QA&A meetings.