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Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Full Survey Due to a Complaint Survey conducted on January 3, 2012, the surveyors finds that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

A. Based on Hospital policy, observation and staff interview, it was determined the Dietary Supervisor failed to ensure dietary staff followed established food storage policies to ensure safe food storage, which has the potential to effect 13 of 13 patients as of 1/3/12.

Findings include:

1. The Hospital policy titled "Food Storage" (last revised 06/2011) was reviewed on 1/3/12. The policy indicated "2. Refrigeration... e. Cheese will be tightly wrapped to prevent drying and absorption of odors. f. Milk will be rotated with each delivery...Milk with the earliest expiration date should be used first. g. All foods will be properly wrapped, dated and labeled and /or stored in sealed containters... 3. All frozen food will be properly wrapped, dated and labeled and put in the freezer..."

2. During a tour of the dietary conducted on 1/3/12 at 2:30 PM, with the head chef and dietician, it was observed the following items were opened with no seal or enclosure to ensure food quality:

In the walk in freezer:
1 bag of meatballs open with no seal or label
1 bag of hushpuppies open with no seal
1 bag of cubed meat with no seal or label of contents
2 meat trays open with no seal
1 bag of spinach open with no seal
1 box of pastries with no seal
1 bag of hamburgers with no seal
1 bag of carrots open with no seal
1 bag of vegetable blend open with no seal

In the walk in refrigerator: 1 bag of mozzarella cheese open with no seal
1 bag of shredded parmesan cheese with visible green discoloration/mold, open with no seal
1 bag of shredded cheddar cheese open with no seal
2 boxes of yellow onions with visible green discoloration/mold

In the reach in refrigerator:
7 cartons of Vitamin D milk with expiration date of 12/31/11

3. During an interview with the Chief Executive Officer (CEO) on 1/3/12 at 3:30 PM, the above findings were confirmed.

B. Based on Hospital policy, sanitizer log and staff interview, it was determined the Dietary Supervisor failed to ensure the dietary staff followed the established procedures related to testing of the sanitizer solution to ensure proper sanitization of dietary items, which has the potential to effect 13 of 13 patients as of 1/3/12.

Findings include:

1. A review of the sanitizer log procedure was completed on 1/3/12. The "Sanitizer Solution Log-U.S.. " indicates "A single site set-up for preparing the sanitizing solution, i.e. at the third compartment pot sink, is recommended. The Sanitizer Solution Log must be completed twice a day for sample testing. "

2. A review of the sanitizer logs was completed on 1/3/12. Documentation on the logs indicated there were 9 days in 2011, from October through December and 1 day in January 2012 when the "twice a day sample testing" was not completed.

3. During an interview with the CEO on 1/3/12 at 3:30 PM, the above findings were confirmed.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Full Survey Due to a Complaint Survey conducted on January 3, 2012, the surveyors find that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the Form CMS-2567, dated 1/3/2012.