Deficiency in Maintaining a Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the kitchen and nourishment rooms, as observed during a survey. In the kitchen, a milky, brown liquid with solid particles was found on the floor behind the ice machine, and debris was present 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 of grey water underneath. Additionally, food debris and a white film were observed on the fryer basket, and a thick grease-like coating was found on the pipes and valves behind the stove. In the nourishment rooms, coffee ground-sized debris and dried food residue were observed on the counter and baseboard. 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 was unaware of the leaking pipes and the debris, while the Dietary Manager acknowledged the cleanliness issues but had not taken steps to address them. Housekeeping staff mentioned a lack of a checklist for cleaning tasks, indicating a gap in the facility's cleaning procedures.
Plan Of Correction
1. All identified areas (kitchen floor, behind/under equipment, walk-in refrigerator, and nourishment rooms) were immediately addressed and cleaned. Deep cleaning on all the affected areas was conducted. The leaking triple sink pipe was repaired, and the area sanitized. Debris and residue in both nourishment rooms were cleaned and sanitized using EPA-registered bleach wipes or appropriate sanitizing agents that were made available in nourishment rooms for as-needed cleaning. 2. A comprehensive inspection of the kitchen and all nourishment rooms was conducted by the 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. The 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 of Environmental Surfaces," proper cleaning procedures, frequencies, and escalation of maintenance issues, and control standards for food service areas. 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.