Observations:
Based on observations of the food and nutrition department, review of facility policy and interviews with staff, it was determined that the facility failed to maintain essential food service equipment in safe operating condition.
Findings Include:
Review of facility procedure titled, " Resources" dated unknown indicates " conduct safety and operation inspections 1. Visually inspect all appliances for damage 2. Inspect electric cords and connections 3. Check Filter hoods above stove 4. Check C02 tank storage containers 5. Test functionality of appliances and proper operation of al controls 6. Lubricate per manufacture's specs as needed. 7. Inspect all tethered gas fed appliances. Document findings in log book 1. Remove damaged items from kitchen use 2. Note any discrepancies 3. Note any service repairs and maintenance in TELS equipment log."
An initial tour of the main kitchen was conducted on July 25, 2024, at approximately 9:35 a.m. with the Food Service Director (FSD), Employee E3 and Administrator, Employee E1 revealed the main kitchen grill as essential food service equipment had 3 burners without no knobs to operate the grill safely. The oven next to the grill also had 3 burners and had one missing knob. The last time the grill was in use was in the morning of July 25, 2024 for grilling breakfast sausages.
On July 25, 2024, at 9:53 a.m. an interview was held with Kitchen Cook, Employee E5 who reported that the last time Employee E5 operated the 3 burners grill was yesterday without the grill knobs.
On July 25, 2024, at 10:00 a.m. an interview was held with Food Operation Manager, Employee E6 reported that the facility had three day cooks staff who operate the grill and it's their responsibility to clean the grill after each use. The grill was used yesterday to cook hamburgers.
On July 25, 2024, at 10:08 a.m. an interview was held with Cook, Employee E9 who reported that the grill has been operating without the turn off and on knobs approximately three weeks and the last time Employee E9 operated the grill was yesterday cooking burgers.
On July 25, 2024, at 10:13 a.m. an interview was held with Cook, Employee E10 reported that the knobs have been missing from the grill for about a month. Employee E10 has been using the grill everyday to cook hamburgers and hot dogs.
On July 25, 2024, at 10:21 a.m. an interview was held with Food Operation Manager, Employee E6 was aware of the knobs being missing on the grill as the maintenance order was placed to replace the knobs.
On July 25, 2024, at 10:31 a.m. an interview was held with Cook, Employee E15 who operated the grill yesterday by cooking burgers without the knobs. During interview Employee E15 stated that a working order has been placed to replace the knobs and that cooks were responsible to clean the grill after the last usage for the day.
Review of the maintenance report on July 25, 2024, at 12:33 p.m. with a Food Service Director (FSD), Employee E3 and Administrator Employee E1 revealed that the facility became aware of the broken grill knobs on July 1, 2024. On July 2, 2024, new knobs were ordered; however, they are on backorder and have not yet been delivered. It has been confirmed that the facility has been operating 3 burner grill without the necessary knobs to safely turn it on and off.
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.6(d) Dietary services
| | Plan of Correction - To be completed: 08/12/2024
The provider submits the following plan of correction in good faith and to comply with Federal regulation. This plan is not admission of wrong doing nor does it reflect agreement with the facts and conclusion stated in the statement deficiencies.
Missing Knobs to the Grille that was ordered received and installed
Food service director completed audit of kitchen equipment's for functioning and missing parts on July 25, equipment missing parts were ordered and installed.
Dietary director will in-service all dietary staff about the following:
Any equipment that malfunction or missing parts must be reported to the Dietary Manager Immediately
Dietary manager will notify Food Service Director
Dietary manager will tag out the equipment until its checked and repaired by maintenance
Dietary Manager will document the malfunctioning equipment in TEL to notify maintenance/director of maintenance that equipment needs immediate repair
Equipment functioning check will be added to daily opening and closing check list for managers
Food Service Director/designee will audit opening and closing check list weekly, Audit kitchen equipment weekly for functioning or missing parts x 4 weeks, then monthly x 3months
Results of audits will be presented at monthly QAPI until substantial compliance is achieved.
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