Non-compliant Hand Washing Fixtures in Kitchen
Penalty
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.