Sanitation Failures in Kitchen and Food Service Areas
Penalty
Summary
Surveyors observed multiple sanitation failures in the facility's kitchen and food service areas. Specifically, two out of three ice scoop holders were found to be visibly soiled, with one containing standing water, and the third also showing signs of contamination. The Maintenance Director confirmed these findings and stated that housekeeping staff were responsible for cleaning the ice scoop holders. Further review with the Housekeeping Director revealed that, despite claims of daily cleaning with soap and water, the ice scoop holders were not clean and contained standing water, which was acknowledged as unacceptable. Additionally, more than twenty plate covers were observed to be visibly worn and frayed, lacking a smooth and cleanable surface as required by professional standards. The plate cover rack itself was also found to be soiled with a sticky residue. These deficiencies were confirmed by the Assistant Dietary Services Supervisor (DSS), who acknowledged that both the plate covers and the rack did not meet cleanliness and sanitation standards. These failures were identified in a facility where 145 residents consumed food prepared in the kitchen and used ice from the affected machines.
Plan Of Correction
F0812 1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: 145 of 180 residents were affected by this deficient practice. On 7/17/25, immediately the maintenance director and designee removed identified soiled ice machine scoop holders and replaced soiled with brand new clean and sanitized ice scoop holders. On 7/18/25, the Dietary Service Supervisor (DSS) and designee removed and discarded all identified worn and frayed meal plate covers, and replaced with smooth, cleanable, and brand new plate covers. On 7/18/25, the Dietary Supervisor and designee removed soiled plate cover rack and replaced with properly cleaned and sanitized plate cover rack. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 7/18/25, the Registered Dietitian, Dietary Service Supervisor (DSS), and designee conducted a facility-wide audit for kitchen equipment, including plate cover, plate cover rack, and ice machine scoop holders, and found no other noncompliance. On 8/5/25 - 8/7/25, the Administrator in-serviced Dietary staff about the facility P&P for food procurement and maintaining all equipment used in the kitchen, emphasizing that all equipment should be cleaned and sanitized, and uncleanable equipment such as worn or frayed plate cover racks should be discarded and replaced. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: The Administrator and Dietary Service Supervisor (DSS) or designee will oversee the process. The dietary supervisor or designee will check all kitchen equipment daily for cleanliness and sanitation. The Administrator or designee will check kitchen equipment randomly and weekly to ensure all equipment is clean and not worn or frayed, and dietary staff are following sanitation processes. Any noncompliance will be reported during morning meetings. The dietary supervisor or designee will be responsible for ordering and replacing any kitchen equipment that is not up to standard per facility P&P. 4. Facility plans to monitor effectiveness of the corrective actions and sustain compliance; Integrate QA Process: The Administrator or designee will be responsible for ensuring the monitoring process remains in place. Any findings and noncompliance will be immediately corrected and presented to the monthly Safety Committee meetings and the Quality Assurance (QA&A) committee meetings. The Plan of Correction was presented at the QA&A meeting on 8/14/25. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for 3 months. 5. Corrective action completion date: 8/23/2025