HospitalInspections.org

Based on observation, staff interview and review of CMS 2567 dated 2/14/12 and CMS 2567B dated 4/4/15 (Centers for Medicare and Medicaid Services - deficiency statement for CMS survey and revisit), the Critical Access Hospital (CAH) failed to ensure that the kitchen was maintained in an orderly and clean manner as there were: at least 22 stained, broken or missing ceiling tiles in the kitchen area; the floor tile in the pot and pan storage area and the entryway to back storeroom were missing 5 tiles with others cracked and chipped; the wall behind the dish machine had areas of chipped and peeling paint; and, the floor under the dish machine had a build up of white-brownish residue that could be broken and loosened by hand. This kitchen, dish room, pot and pan storage area and entryway to back storeroom were all interconnected and was the only kitchen for the CAH. This failed practice has the potential to affect patients receiving meals that were prepared at the CAH.

Findings area:

A. Tour of the kitchen on 1/5/16 from 9:45 AM to 10:20 AM with the Dietary Supervisor revealed: 22 ceiling tiles that were stained, cracked and/or missing in the main kitchen area. A review of the CMS 2567 dated 2/14/12 (last full survey completed at the hospital) revealed this same problem was identified at that time. A review of the CMS 2567B dated 4/4/15 from the revisit (resurvey to ensure deficiencies from survey were corrected) revealed the deficiency was corrected.

Interview with the Maintenance Supervisor on 1/6/16 from 9:00 AM to 9:35 AM revealed, "Two maintenance workers had looked above the ceiling in the kitchen and think that the stains are coming from condensation on the air conditioning ductwork above the ceiling tile".

B. Tour of the kitchen on 1/5/16 from 9:45 AM to 10:20 AM with the Dietary Supervisor revealed: 2 floor tile in the pot and pan storeroom and 2 tile in the entryway to the back storeroom were missing, which resulted in a slight dip in the floor that had a dried black residue. Other areas of the floor tile in the pot and pan storeroom were chipped and cracked. There was one area where 4 tiles came together that was bubbled up. These 4 tiles had black and brown residue observed on the tile.

Interview with the Dietary Supervisor during this tour from 9:45 AM to 10:20 AM revealed the "dietary employees try to get it clean but if they scrub too hard the floor tile will pop off and it is asbestos tile".

Interview with the Maintenance Supervisor on 1/6/16 from 9:00 AM to 9:35 AM revealed the CAH had "nothing in the works for replacing the tiles until yesterday when they contacted a company".

C. Tour of the kitchen on 1/5/16 from 9:45 AM to 10:20 AM, revealed the wall behind the dish machine had peeling and chipping paint. The floor under the dish machine (close to the back wall) had a build up of white-brownish residue that could be broken loose with your hand.

Observation of the kitchen on 1/7/16 at 10:15 AM revealed the floor under the dish machine had been cleaned and there was not as much white-brownish residue.

Interview with the Dietary Supervisor revealed "one of the dietary employees had worked on the floor and they thought with one more try they could clean most of the white-brownish residue up".