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Based on document review, observation and interview, it was determined the Hospital failed to ensure the dietary staff followed established policies and procedures to maintain a sanitary food service environment. This has the potential to affect all patients and visitors receiving dietary food services from the hospital.

Findings include:

1. The Hospital policy titled "Dress Code & Personal Grooming" (revised 4/2014) was reviewed 7/1/14. The policy stated "III. Procedure: 2. No...hats or other covers are to be worn with exception of the designated approved caps, bonnets, or hairnets".

2. A tour of the dietary department with the food service manager (E #14) was conducted 7/1/14 at approximately 9:45 AM. E #12 ( a cook) had a baseball style cap on with approximately 4 inches of hair unrestrained. E #13 (food service coordinator) had a hairnet half way on with hair exposed in the front.

4. During an interview on 7/1/14 at approximately 11:50 AM, E #14 stated the cook and the food service coordinator had hair exposed which should have been restrained.

5. The Hospital policy titled "Prevention of Contamination" (revised 3/2014) was reviewed 7/1/14. The policy required, "III. All food...Containers will be labeled and dated".

6. A tour of the dietary department with E #14 was conducted on 7/1/14 at approximately 9:45 AM. Approximately 50 opened and undated spices containers (examples: 5 pounds Chili Powder, 6 ounces Oregano, 5 pounds of Paprika, 3 pounds white pepper and 3 pounds red pepper) were in the hot food area.

7. During an interview on 7/1/14 at approximately 10:30 AM, E #14 stated all spices should be labeled when they are opened.

8. During an interview on 7/1/14 at approximately 2:00 PM, the director of food service (E #17) stated "we have been waiting on labels". They have been on back order but I guess we could use a sharpie to label them (spices).

Surveyor: Jones, Terry

CONDITION: Based upon on-site observation, staff interview, and document review during the Life Safety portion of a Medicare Full Survey due to Complaint conducted on April 9 - 11, 2014, the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the severity, variety, and number of Life Safety Code deficiencies that were found. Also see A 710

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STANDARD: Based upon on-site observation, staff interview, and document review during the Life Safety portion of a Medicare Full Survey due to Complaint conducted on April 9 - 11, 2014, the surveyor finds that the facility does not comply with NFPA 101 - 2000, the Life Safety Code

This is evidenced by the severity, variety, and number of Life Safety Code deficiencies that were found. Also see K-tags Cited for Survey dated 04/11/2014

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