Facility I.d. Number: 0045526
Date of Survey: 04/29/03
The facility shall have written policies and procedures, governing all services provided by the facility which shall be formulated be a Resident Care Policy Committee consisting of at least the administrator, the advisory physician or the medical advisory committee and representatives of nursing and other services in the facility. These policies shall be incompliance with the Act and all rules promulgated thereunder. These written policies shall be followed in operating the facility and shall be reviewed at least annually by this committee, as evidenced by written, signed and dated minutes of such a meeting.
Each facility shall have policies covering disaster preparedness, including a written plan for staff, residents, and others to follows.
Every facility shall comply with the Departments rules entitled Food Service Sanitation (77 Ill. Adm. Code 750)
At all times, including while being stored, prepared, displayed, served, or transported, food shall be protected from potential contamination, including dust, insects, rodents, unclean equipment and utensils, unnecessary handling, coughs and sneezes, flooding, drainage, and overhead leakage or overhead drippage from condensation. Prior to July 1, 1996, the temperature of potentially hazardous foods shall be 45 degrees F or below or 140 degrees F or above at all times, except as otherwise provided in this Part. Effective July 1, 1996, the temperature of potentially hazardous foods shall be 410F or below, or 1400 F or above, at
all times, except as otherwise provided in this Part. Refrigeration units unable to maintain a product temperature of 410 F may continue to be used until January 1, 2006, provided the product temperature is maintained at 450 F or less at all times and all potentially hazardous foods prepared on-site or opened containers/packages of commercially processed food products are dated and refrigerated for no longer than three days after preparation or opening, respectively. In the event the dated product is not used or sold within 3 days, the product shall be discarded.
To prevent cross-contamination, kitchenware and food-contact surfaces of equipment shall be washed, rinsed, and sanitized after each use and following an interruption of operations during which time contamination may have occurred. Non-food contact surfaces of equipment shall be cleaned as often as is necessary to keep the equipment free of accumulation of dust, dirt, food particles, and other debris.
All plumbing shall be sized, installed, and maintained in accordance with applicable provisions of the Illinois State Plumbing Code. Local ordinances may be followed when standards are equal to or exceed those contained in the aforementioned Code. There shall be no cross-connection between the safe-water supply and any unsafe or questionable water supply, or any source of pollution through which the safe water supply might become contaminated.
Each facility shall:
Maintain all electrical, signaling, mechanical, water supply, heating, fire protection, and sewage disposal systems in safe, clean and functioning condition. This shall include regular inspections of these systems.
These regulations are not met as evidenced by:
Based on observation, staff interview, policy review and review of photographs, the facility failed to prepare, distribute and serve food under sanitary conditions. The facility failed to follow its policy of shutting down the entire kitchen area when sewage water had backed up into the kitchen.
Surveyor arrived at facility at 2:15p.m. and interviewed E2, Director of Nurses, about a kitchen flood. E2 stated a drain was stuffed, it was cleaned out and everything was over by 11a.m.
During interview on 4-24-03 at 2:30p.m. in the kitchen E3, Food Service Supervisor, stated she was called by kitchen staff at 8a.m. and was told water was backing up into the kitchen from the drains in the floor. E3 stated she arrived at 9a.m. E3 was asked several times how deep the water was and was very hesitant to answer question. E3 finally stated the water on the kitchen floor was deep enough to wet the bottom of her pants.
E3 stated the water covered the cooking area, dish room, hallway next to dish room where carts are stored, breakdown area next to dish room and down hallway to east outside doorway (about 30 feet from cooking area). Four drains in these areas were backing up. During this interview E3 stated staff stood on milk crates to cook lunch because of the water in the kitchen. E3 did state that at noon meal paper products were used for food service because dishes could not be cleaned. E3 stated paper products would be used for the evening meal also. E3 stated she knew food service should have been suspended. When asked why service was not suspended E3 stated she did not have the authority to
suspend the food service. E3 said E2, Director Nurses, was in charge of the building and did not give E3 any direction to suspend food service.
E3 was asked about facility policy regarding suspension of food service and E3 stated she had no policy available about suspending food service. When surveyor arrived in kitchen at 2:30p.m. staff were mopping floors of cooking area and hallway. Approximately ½ to 3/4 inches of dirty water remained on the floor in the dish room. E3 was asked how staff were assuring that kitchen was adequately cleaned and sanitized and E3 stated bleach and pink soap are being used with hot water from the coffee machine. E3 could not state actual dilution of bleach to water for sanitizing purposes.
On 4-24-03 at 4:10p.m. E4, dietary aide, was interviewed and stated she arrived at facility on 4-24-03 at 5a.m. and at this time there was about 1 ½ inches of water on the floor all the way to the stove. Food preparation was done for two meals (breakfast and lunch) while cook stood in water and other staff had to walk through water. The water looked sooty and did smell like sewer water. Regular dishes were used at breakfast because they had been washed the night before. Paper and plastic were used at lunch because dish machine could not be run because of the back up of water in kitchen and dish room.
On 4-24-03 at 4p.m. E7, dietary aide, was interviewed and stated water was about ankle deep in kitchen while lunch was being prepared.
On 4-24-03 at 4p.m. E6, dietary tech, was interviewed and stated she started work at 10:30a.m. and water was ankle deep in cooking area of kitchen. There was no water in the prep area where refrigerator and freezer are located. On 4-24-03 at 4:20p.m. E2, Director of Nurses, was interviewed in the dining room and stated food service should have been stopped when there was flooding in the kitchen. Surveyor asked E2 why the food service was not stopped and E2 did not answer this question. E2 was asked for policy regarding situations when food service would be suspended and E2 stated policies were locked up in Administrators office and would be available on 4-25-03.
On 4-24-03 at 2:45p.m. E8, maintenance, was interviewed and stated he was told about problem between 7a.m. and 8a.m. and at this time there was no water in kitchen yet. Water was leaking into the basement. A plumber was called, arrived about 10a.m., rodded out the drain and everything was over at 11a.m. E8 could not state how deep water was in kitchen.
On 4-25-03 Z2 was interviewed and stated he was called to facility the morning 4-24-03 because of a clogged drain. He stated the drain was located by the dish room (breakdown area). Drain was rodded and it was a quick job. Surveyor asked Z2 how much water was on floor and he stated the floor was wet enough for a good mopping. He was asked if water was over an inch deep and stated it was not that deep. Z2 was asked what the water looked like and he stated he really didn't notice what the water looked like.
Z2 was asked how much water was in hallway and he stated he did not remember. Z2 was asked if he was in cooking area of kitchen on 4-24-03 and stated he was not in the kitchen cooking area.
On 4-24-03 at 5:05p.m. surveyor entered kitchen and observed staff washing walls of kitchen directly next to steam table being filled for evening meal. E3 was questioned why staff were cleaning right next to steam table and E3 stated kitchen needed to be cleaned. At 5:10p.m. surveyor informed E3 that food prepared in kitchen should not be served but the decision is to be made by facility.
E2 was also notified of recommendations by the Department that food should not be served from the kitchen and that the
kitchen be closed and professionally cleaned. At this time E2 stated the kitchen will be closed and a cleaning agency will be called to clean kitchen so breakfast can be served.
At 5:17p.m. surveyor observed dietary staff at elevator waiting to take steam tables to floors for dinner. At 5:30p.m. second floor resident were being served dinner. At 5:45p.m. residents in first floor dining room were served dinner. At 6p.m. resident of 4th floor were served dinner. At 6:10p.m. 6th floor residents were served dinner and 5th floor would be served after 6th floor residents. All facility residents were served food from kitchen.
It was observed that residents were served from regular type dinner wear at the evening meal. At 6:16p.m. surveyor asked E3 why paper products were not being used to serve residents as she had previously stated. E3 replied that she ran out of paper products after serving lunch. E3 stated the dishes were washed and sanitized by dish machine at 1p.m. As previously stated surveyor observed approximately ½ to 3/4 inches of dirty water on the floor in the dish room at 2:30p.m. At this time staff were still in process of cleaning the kitchen.
Photographs taken on 4-24-03 were provided to surveyor on 4-24-03. These photos show large amounts of black substance in water in the dish room and breakdown area. Photos also show water in kitchen cooking area.
Facility policy for Kitchen Closure states 'It is the policy of this facility that if sewage water backs up into the kitchen the facility will close the entire kitchen area down. The kitchen will not reopen until all sanitation requirements are met. Until the kitchen can reopen, food will be obtained from an outside food source.'
Interview with E1, by phone on 4-28-03, confirmed that food service is to be stopped and the kitchen shut down if water is found to be backing up from drains in kitchen.