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Based on observation and a tour of the facility, the facility did not have an organized dietary service that was directed and staffed by adequate and qualified personnel. This could potentially affect the entire patient census.

Findings were:

During a tour of the facility kitchen on 3-5-14, the following dietary issues were identified:

· A tour of the dishwashing area revealed a mobile cart used for the drying of clean dishes that contained dishes with dried food residue and a dark, viscous, oil-like residue. The dishes on the same cart were stored upright with their cooking/serving surfaces exposed to dust and debris. The ceiling tiles of the dishwashing area were discolored and covered with brown spots.

· Upon opening the kitchen's chest freezer, the temperature was noted by the surveyor to be 18 degrees Fahrenheit, although the temperature log for the same freezer revealed consistent, daily temperatures of 0 degrees Fahrenheit for March 1st through March 5th. The interior of the same freezer was caked in 3-4 inches of ice build-up.

· Upon opening the kitchen's "ice cream box", the temperature was noted by the surveyor to be 20 degrees Fahrenheit, although the temperature log for the same freezer revealed consistent, daily temperatures of NEGATIVE 20 degrees Fahrenheit for March 1st through March 5th.

· Upon opening the kitchen's upright freezer #1, the temperature was noted by the surveyor to be 3 degrees Fahrenheit, although the temperature log for the same freezer revealed consistent, daily temperatures of NEGATIVE 7 degrees Fahrenheit for March 1st through March 5th.

· A tour of the facility's kitchen revealed a heated food cart (used to transport meals to patients) with a hardened, discolored, greasy residue along the seams. The same food cart contained a filter over the motor's intake area that was covered in dusty, greasy residue.

· An inspection of kitchen upright freezer #4 revealed a bag of frozen asparagus, 2 bags of frozen french fries and a bag of frozen, breaded chicken strips. All 4 bags had been opened for use but not resealed, thus exposing them to freezer-burn and bacteria. None of the 4 bags had been dated, therefore giving no indication as to when they had been opened. The same freezer revealed a dried and crusty residue on the inside floor.

· 1 of 1 soup pot located under the dry goods cabinet was covered with a plastic lid that had previously broken but was held together with adhesive tape.

· The cabinet in the dry goods area contained 2 bags of dry pancake mix, a plastic bag of coconut flakes and a plastic bag of brown sugar. None of the 4 bags had been resealed, thus allowing them to be accessed by insects and rodents. None of the 4 bags contained a date on which they had been opened.

· The countertop in the dry goods area was partially covered in a piece of unfinished plywood (to cover an unused sink area). The area around the edges of the plywood were caked in a hard, greasy residue. The unfinished wood portion of the countertop could not be properly cleaned.

· On the countertop near a rear sink in the kitchen was a plastic bucket containing fish fillets. The water in the bucket was room-temperature to the surveyor's touch.

· On a second countertop near the rear sink in the kitchen was a 10-lb plastic sleeve/chub of ground beef, which had been left to thaw on the countertop and was room-temperature to the surveyor's touch.

· Located in the rear sink were 8 plastic, gallon-sized zippered bags containing (what appeared to be) frozen fish, thawing in a plastic tub of water. The bags were not dated and were unlabeled as to their contents. Also located in the same sink was a 5-lb plastic container of frozen "Chopped BBQ", sitting in the sink to thaw.

· The kitchen's dry goods pantry contained 3 bottles of commercial salad dressing that had been opened for use but not refrigerated after opening.

· The kitchen exit nearest the Director's office door was stacked with 4 bags of garbage that had not been taken to the dumpster, thereby attracting insects and rodents.


The above was confirmed in an interview with the facility Administrator, Director of Nursing, Chief Compliance Officer and Director of Infection Control the afternoon of 3-6-14.

Based on observation and a tour of the facility, the hospital did not provide a sanitary environment to avoid sources and transmission of infections and communicable diseases.

Findings were:


During a tour of the facility on 3-5-14, the following infection control issues were identified:

· A tour of ER Room #4 revealed dust on all high, horizontal surfaces as well as an access panel in the ceiling with three holes of approximately 1" wide each opening into the attic area, allowing the passage of dust, insects and rodents into the room.

· A tour of ER Room #1 revealed dust on all high, horizontal surfaces.

· A tour of the ER hallway revealed dust covering 1 of 1 portable x-ray machine.

· A tour of the surgical recovery room revealed 2 clean blankets, folded and ready for use, stored on top of the soiled laundry bin.

· A tour of the scrub area located outside the procedure room revealed 2 missing ceiling tiles (revealing exposed wiring and water pipes) that did not protect the area from dust, insects and rodents as well as 5 ceiling tiles with extensive water damage.

· A tour of Endoscopy Room #3 revealed dust on all high, horizontal surfaces.

· A tour of Endoscopy Room #1 revealed dust on all high, horizontal surfaces as well as a dried, reddish-brown substance on the surgical bed frame, underneath the mattress.

· A tour of the Treatment Room revealed dust on all high, horizontal surfaces.

· A tour of the facility's kitchen (dishwashing area) revealed a mobile cart used for the drying of clean dishes that contained dishes with dried food residue and a dark, viscous, oil-like residue. The dishes on the same cart were stored upright with their cooking/serving surfaces exposed to dust and debris. The ceiling tiles of the dishwashing area were discolored and covered with brown spots.

· A tour of the facility's kitchen revealed a heated food cart (used to transport meals to patients) with a hardened, discolored, greasy residue along the seams. The same food cart contained a filter over the motor's intake area that was covered in dusty, greasy residue.

· An inspection of kitchen upright freezer #4 revealed a bag of frozen asparagus, 2 bags of frozen french fries and a bag of frozen, breaded chicken strips. All 4 bags had been opened for use but not resealed, thus exposing them to freezer-burn and bacteria. None of the 4 bags had been dated, therefore giving no indication as to when they had been opened. The same freezer revealed a dried and crusty residue on the inside floor.

· 1 of 1 soup pot located under the dry goods cabinet was covered with a plastic lid that had previously broken but was held together with adhesive tape.

· The countertop in the dry goods area was partially covered in a piece of unfinished plywood (to cover an unused sink area). The area around the edges of the plywood were caked in a hard, greasy residue. The unfinished wood portion of the countertop could not be properly cleaned.

· On the countertop near a rear sink in the kitchen was a plastic bucket containing fish fillets. The water in the bucket was room-temperature to the surveyor's touch.

· On a second countertop near the rear sink in the kitchen was a 10-lb plastic sleeve/chub of ground beef, which had been left to thaw on the countertop and was room-temperature to the surveyor's touch.

· Located in the rear sink were 8 plastic, gallon-sized zippered bags containing (what appeared to be) frozen fish, thawing in a plastic tub of water. The bags were not dated and were unlabeled as to their contents. Also located in the same sink was a 5-lb plastic container of frozen "Chopped BBQ", sitting in the sink to thaw.

· The kitchen's dry goods pantry contained 3 bottles of commercial salad dressing that had been opened for use but not refrigerated after opening.

· The kitchen exit nearest the Director's office door was stacked with 4 bags of garbage that had not been taken to the dumpster, thereby attracting insects and rodents.

· An open bag of "cat chow" was found under the desk in the Dietary Director's office. 2 cats (without collars or other means of identification) were noted by the surveyor to be walking around in the open, public area between the hospital and the clinic on the afternoon of 3-5-14.


The above was confirmed in an interview with the facility Administrator, Director of Nursing, Chief Compliance Officer and Director of Infection Control the afternoon of 3-6-14.