Sanitary Deficiencies in Food Service Areas
Penalty
Summary
The facility was found to have deficiencies in maintaining sanitary conditions in its food service areas, as required by the State Sanitary Code. During a Life Safety Code recertification survey, surveyors observed a buildup of a white and/or brown colored substance around the ice dispensers in several locations, including the kitchenette in the Hiru unit, the nurse station in the Inn unit, the kitchenette in the Sunset Hall unit, and the employee cafeteria. The Engineering Manager confirmed that the Dietary Department is responsible for cleaning the ice machines, which are supposed to be cleaned weekly. Additionally, the surveyors noted that pendent sprinkler heads were heavily dusted in the kitchenette of the unnamed unit and by the three-compartment sink area in the kitchen. The Senior Director of Operations acknowledged the presence of dust on the sprinkler heads and stated that they would be cleaned. These observations indicate a failure to maintain food contact surfaces and sprinkler system components in a clean condition, as required by the sanitary code.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Plan of Correction for affected areas: No residents were identified. Action taken: All ice machines in the community were cleaned by dining staff. On (MONTH) 18, 2024, the maintenance staff cleaned the identified sprinkler pendants in the kitchenette in the (NAME) unit and by the three-compartment sink in the main kitchen. Plan of Correction to identify other areas potentially affected: The facility acknowledges that all residents have the potential to be affected by this practice. The maintenance staff checked all sprinkler pendants throughout the building for dust or foreign material. Any pendants with dust or foreign material were cleaned. On 12/31/24, the FSD, RDO, and RD’s were educated on how to properly clean the outside/chute of the ice machines, avoiding the internal areas of ice production to avoid contamination of chemicals with ice. Plan of Correction for system measures to prevent reoccurrence: As a systemic change, the FSD or designee will round in the kitchenettes/café weekly to ensure compliance with ice machine cleaning. Dining staff will be responsible for cleaning the ice machines weekly. Cleaning compliance will be documented and audited by the FSD and/or designee weekly. All maintenance staff will receive additional education, and all participants will understand the life safety issues with sprinkler pendants that must be installed and maintained free of dust and foreign material. The In-Service Coordinator has been assigned the responsibility for the education of staff. This education will also be provided to all new maintenance staff and will be reviewed when concerns are identified. The Director of Maintenance or designee will inspect the sprinkler pendants monthly for dust and foreign material and utilize an audit tool to document the findings and report the audit findings to the Quality Assurance/Quality Improvement Committee monthly for a period of six (6) months. Plan of Correction for monitoring corrective actions: The FSD or designee audits will be compiled with findings reported to the QAPI committee for review for 6 months. The Director of Maintenance or Designee will review monthly audits for any cases of non-compliance. The Director of Maintenance or Designee will report the result of the audits to the Quality Assurance/Quality Improvement Committee on a monthly basis for 6 months, as well as the correction plan if warranted. Responsibility: Director of Operations Compliance Date: January 27, 2025