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Based on observation, staff interview, review of facility procedures and service records, and quality assurance program information, the facility failed to implement a system that ensured dietary staff were knowledgeable regarding the importance of taking action to correct inadequate final rinse temperatures of the dish machine and implementing alternatives to ensure resident dinnerware and utensils were effectively sanitized. When tested during the survey it was determined the temperature of the dish machine rinse water was not sufficient to sanitize. Review of the rinse temperature logs showed the rinse water temperatures had been failing for six months; however, the problem was not resolved nor were there any alternative sanitation methods used during those times. Therefore this resulted in a determination of immediate jeopardy on 9/24/12 at 6:50 PM for all residents of the facility. The census was 2. The hospital's action plan included immediate changes to include:
a. Use of a 3 compartment manual method to sanitize dishes/utensils, and use of disposable items for meal services for all meals for the next 48 hours.
b. Education to all nursing and dietary staff related to the disposable service ware, and manual dish washing/sanitizing method for all dietary staff.
c. Service call to the equipment manufacture to repair the dish machine.
d. A quality assurance monitoring study was put into practice related to the manual sanitation of the dishes.
The action plan was accepted on 9/25/12 at 5:20 PM, and the immediate jeopardy was abated at 5:30 PM. However, deficient practice remained at a standard level deficiency.

1. Refer to C279 for details related to the dish machine equipment failure and ineffective sanitation. The details include the history of the problem and the facility's knowledge and time frame related to the failure to take corrective measures.

2. Refer to C341 for details related to the lack of monitoring and action by the facility and its failure to include kitchen sanitation issues as a part of the quality assurance program.

Based on observation, staff interview, and review of facility procedures and service records, the facility failed to implement a system that ensured dietary staff were knowledgeable regarding the importance of taking action to correct inadequate final rinse temperatures of the dish machine and implementing alternatives to ensure resident dinnerware and utensils were effectively sanitized to minimize the potential for food-borne illness. When tested during the survey it was determined the temperature of the dish machine rinse water was not sufficient to sanitize. Review of the rinse temperature logs showed the recorded hot rinse temperatures had been inadequate for six months; however, the problem was not resolved nor were there any alternative sanitation methods used during those times. Therefore this resulted in immediate jeopardy for all residents of the facility. The census was 2. The findings were:

Review of the September 2012 dish machine log showed the hot water rinse temperature was recorded 3 times most days and as of 9/24/12 sixty-two of the recorded temperatures were less than the required 180 degrees F to sanitize the dishes and utensils, 39 of those times, the temperatures were less than or equal to 160 degrees F. Interview with the Certified Dietary Manager (CDM) at 4:20 PM on 9/24/12 revealed she was aware of the low hot water temperatures on the log, and reported it had been a problem for the last six months. Continued interview with the CDM revealed the recorded temperatures were taken by looking at a temperature gauge located on the outside of the dish machine. The manager then verified an internal temperature was not taken to her knowledge in the past six months, neither by using a temperature strip indicator or a holding thermometer. She further revealed there was no alternative method used to sanitize the dishes when the machine was known not to be working properly. She stated she "hoped" it was a problem with the temperature gauge. The manager also stated there were a couple of times when the maintenance director worked on the machine and was not successful in getting the water to maintain a sufficient temperature (180 degrees F) to sanitize. However, she did not know of anything else that was done to fix the problem.

Review of the past six months of temperature logs showed the following number of times the dish machine rinse temperature was recorded as 160 degrees F or lower:
a. 10 times ineffective temperatures were recorded in April 2012. With low temperatures ranging from 145 degrees to 160 degrees F.
b. 6 times the temperatures were low in May 2012 with the low temperatures ranging from 155 degrees to 160 degrees F.
c. 12 times the temperature was recorded to be too low in June 2012 with the temperatures ranging from 150 to 160 degrees F.
d. 25 times in July 2012 with the temperatures ranging from 120 to 160 degrees F.
e. 42 times in August 2012 with the temperatures ranging from 120 to 160 degrees F.
f. 39 times as of September 24, 2012 with the temperatures ranging from 115 to 160 degrees F.

A test of the internal dish machine hot water temperature was done on 9/24/12 at 5:20 PM by the surveyor and witnessed by the CDM. The test was performed using indicator stickers (thermolabels) designed to turn black when the dish surface reaches 160 degrees F when run through the dish machine cycle (160 degrees F at the rack level/dish surface reflects 180 degrees F at the manifold, which is the area just before the final rinse nozzle where the temperature of the dish machine is measured). During two tests of the dish surface temperature, the thermolabels failed to turn black.

According to Food Code 2009, U.S. Public Health Service: 4-501.112 "(A) Except as specified in ? (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90oC (194oF), or less than... (2) For all other machines, 82oC (180oF)."

The following additional concerns were noted related to a lack of action taken to the known problem with the dish machine and the susceptibility of the population being served:

According to Food Code 2009, U.S. Public Health Service: "Highly susceptible population means PERSONS who are more likely than other people in the general population to experience foodborne disease because they are:
(1) Immunocompromised...or older adults; and
(2) Obtaining FOOD at a facility that provides services such as...health care, or assisted living...adult day care center, kidney dialysis center, hospital or nursing home..."

1. Interview with cook #1 on 9/24/12 at 6:20 PM revealed she used the dish machine most days and the rinse temperature was usually between 142 and 160 degrees F. She stated she used the external temperature gauge to read the temperature and would record it on the sheet. She further verified the dish machine continued to be used even when ineffective temperatures were being seen. She stated she reported the problem many times and the maintenance director tried to make adjustments; however, the temperatures remained a problem.

2. Review of the facility's chemical supply company orders/invoices showed the supplier would sometimes test the condition of equipment when checking inventory levels. Review of these order/invoices on 9/14/12, 6/19/12, and 4/10/12 showed the dish machine was checked on these dates and the final rinse temperature was recorded respectively as 170, 160, and 170 degrees F. Further review of these reports showed although the temperatures were not adequate to sanitize, there was nothing documented in the comments or results section to recommend any changes or further action to be taken. Additionally it did not indicate how the temperatures were taken.

3. Interview with the consultant Registered Dietition (RD) on 9/26/12 at 9:20 AM revealed he sometimes checked the equipment when he was on-site. He stated if a problem was noticed or brought to his attention, he would document the concern or recommendations in his report, or sometimes just discuss it with the dietary manager. He verified he was not aware of the length of time the dish machine temperatures had been problematic. Review of the RD monthly reports from April to September 2012 showed no mention of this sanitation problem except on September 5, 2012. In this report the RD recognized the final rinse temperature of the dish machine was a problem noting it was low at 150 degrees F. His note recommended re-checking the temp 2-3 more times and referring to the sanitation regulations or the manufacturer's recommendations. However, interview with the administrator on 9/26/12 at 4 PM verified there was no follow-up to this report to show if corrective measures where implemented.

On 9/24/12 at 6:50 PM, the administrator was notified of the immediate jeopardy. The hospital's action plan included immediate changes to include:
a. Use of a 3 compartment manual method to sanitize dishes/utensils, and use of disposable items for meal services for all meals for the next 48 hours.
b. Education to all nursing and dietary staff related to the disposable service ware, and manual dishwashing/sanitizing method for all dietary staff.
c. Service call to the equipment manufacture to repair the dish machine.
d. A quality assurance monitoring study was put into practice related to the manual sanitation of the dishes.
The action plan was accepted on 9/25/12 at 5:20 PM, and the immediate jeopardy was removed at 5:30 PM.

Based on observation, staff interview and review of quality assurance program information, the facility failed to ensure identified sanitation issues in the dietary department were monitored and corrected. The in-patient census was 2. The findings were:

Review of the September 2012 dish machine log showed the hot water rinse was recorded 3 times most days and as of 9/24/12 sixty-two of the temperatures recorded were less than the required 180 degrees F to sanitize the dishes and utensils. Interview with the Certified Dietary Manager (CDM) at 4:20 PM on 9/24/12 revealed she was aware of the low hot water temperatures on the log, and stated it had been a problem for the last six months. Continued interview with the CDM revealed the recorded temperatures were taken by looking at a temperature gauge located on the outside of the dish machine. The manager further revealed there was no alternative used to acquire a temperature or to sanitize the dishes when the machine was known not to be working properly. She stated she "hoped" it was a problem with the temperature gauge. The manager also stated there were a couple of times when the maintenance director worked on the machine at her request and was not successful in getting the water to maintain a sufficient temperature (180 degrees F) to sanitize. She further revealed she did not know of any other actions taken to fix the problem.

Interview with the administrator and the quality assurance (QA) coordinator on 9/26/12 at 5:30 PM verified the dietary department participated in the QA program. However, there was not any specific measure identified, being tracked, or being reported on related to kitchen sanitation issues. Review of the QA program information showed the information being collected and reported was on nutrition screening and other medical nutrition topics. Further, the administrator verified the issue of the dish machine was something that should have been reported on and sanitation issues such as that should be routinely monitored and incorporated into the QA program.

The following additional concerns were noted related to a lack of action taken to the known problem with the dish machine:

1. Interview with cook #1 on 9/24/12 at 6:20 PM revealed she used the dish machine most days and the rinse temperature was usually between 142 and 160 degrees F. She stated she used the external temperature gauge to read the temperature and would record it on the sheet. She further verified the dish machine continued to be used even when ineffective temperatures were being seen. She stated she reported the problem many times and the maintenance director tried to make adjustments; however, the temperatures remained a problem.

2. Review of the facility's chemical supply company orders/invoices showed the supplier would sometimes test the condition of equipment when checking inventory levels. Review of these order/invoices on 9/14/12, 6/19/12, and 4/10/12 showed the dish machine was checked on these dates and the final rinse temperature was recorded respectively as 170, 160, and 170 degrees F. Further review of these reports showed although the temperatures were not adequate to sanitize, there was nothing documented in the comments or results section to recommend any changes or further action to be taken. Additionally it did not indicate how the temperatures were taken.

3. Review of the registered dietitian (RD) monthly reports from April to September 2012 showed no mention of this sanitation problem except on September 5, 2012. In this report the RD recognized the final rinse temperature of the dish machine was a problem noting it was low at 150 degrees F. His note recommended re-checking the temp 2-3 more times and referring to the sanitation regulations or the manufacturer's recommendations. However, interview with the administrator on 9/26/12 at 4 PM verified there was no follow-up to this report to show if corrective measures where implemented.