Non-compliant Hand Washing Fixtures in Kitchen
Summary
The facility failed to ensure that hand washing fixtures in the food preparation areas of the kitchen were compliant with regulatory requirements. During a recertification survey, it was observed that the hand washing sink in the food prep area adjacent to the refrigerator was equipped with 3-inch long blade handles instead of the required 4-inch wrist blade handles. This deficiency was noted in 2 out of 3 food prep locations in the kitchen. The Director of Maintenance acknowledged the finding during an interview conducted at the time of the survey.
Plan Of Correction
Plan of Correction: Approved March 31, 2025 Element #1: The following actions were accomplished for the resident(s) identified in the deficient practice: - 4-inch wrist blade handles were installed on the hand washing sink in the food prep area on 3/24/25. - An audit of the sinks in the kitchen was conducted on 3/25/25 and no other concerns were identified for the hands-free fixtures. Element #2: The following actions will be implemented to identify other residents who have the potential to be impacted by the deficient practice: - All residents have the potential to be affected; however, no residents were negatively impacted. Element #3: The following system changes will be implemented to prevent reoccurrence: - Kitchen and maintenance staff will be educated by the administrator on the wrist blade hand free fixtures and requirement in the event future repairs are needed. A record of education will be maintained for reference and validation. Element #4: The facility’s compliance with the corrective action will be monitored using the following quality assurance system: - The Director of Maintenance/designee will audit 1 x week for 4 weeks, then monthly thereafter for 3 months. Negative findings will be corrected immediately and reported to the administrator. - Results of audits will be reviewed during monthly QAPI meetings and the QAPI committee will determine ongoing audit frequency after three months of compliance. Element #5: The person responsible for the corrective action is the Director of Maintenance/designee. Date of Compliance is 4/18/25.
Penalty
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