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Based on observation, document review, and interview, the Governing body failed to:

A. protect patients' rights by not maintaining a safe environment for patients receiving care at this facility. The facility had knowledge of buildings 509 and 510 having a potential mold problem and delayed the resolution of the problem. Patients (residents) continue to occupy and live and receive their meals in these buildings.

Refer to tag A115, A144


B. maintain the building that would provide a safe environment for patients receiving care at this facility. The facility had knowledge that buildings 509 and 510 having a potential mold problem and delayed the resolution of the problem. Patients (residents) continue to occupy and live and receive their meals in these buildings.

Refer to tag A700



C. provide a sanitary environment for the preparation and serving of food to the patients seeking care at the facility. The dining area where patients consume their food was potentially contaminated with mold and the facility delayed the evaluation, testing and possible need for cleaning of the environment. Patients continue to use this dining room.

Refer to tag A747

Based on observation, document review, and interview, the facility failed to protect patients' rights by not maintaining a safe environment for patients receiving care at this facility. The facility had knowledge of buildings 509 and 510 having a potential mold problem and delayed the resolution of the problem. Patients (residents) continue to occupy and live and receive their meals in these buildings.

Refer to tag A144

Based on observation, document review, and interview, the facility failed to maintain a safe environment for patients receiving care at this facility. The facility had knowledge of buildings 509 and 510 having a potential mold problem and delayed the resolution of the problem. Patients (residents) continue to occupy and live and receive their meals in these buildings.

A tour of the patient dining room, food prep-area and food service area located in San Jacinto Unit (building 509 and 510), on 10/20/2015, was conducted with administrative staff and maintenance staff #1, #2, #3, #4, #5, #7, #8, and #10. During the tour, the following were observed:

A black substance was observed around the dishwasher. The black substance had stained the once white calk where the dishwasher met the wall. Staff #11 and #12 stated they had tried all the cleaners on hand including bleach. The black substance would fade to a lighter color but would quickly return to the black color that was observed.


The handwashing sink located in the food prep-area had a black substance that had stained the once white calk where the sink met the wall. The foot operated water control paddles for the handwashing sink was covered with dust, dirt, and a black substance. The peddles had the appearance of not being cleaned.


A black, sticky looking substance was observed inside of the icemaker. This machine produced ice for patient use. Staff #7 and #9 were shown the black, sticky looking substance in the ice machine and confirmed the machine was in need of cleaning and disinfected.


The handles on the cabinets in the food prep-area had a buildup of a black crusty residue leaving the handles unsanitary. Food supplies were being stored in these cabinets. These cabinets were frequently accessed by the kitchen personnel with their bare hands.


The pull handles for the drawers in the food prep-area had a buildup of a black crusty residue leaving the handles unsanitary. Food supplies and food serving utensils were being stored in these drawers. These drawers were frequently accessed by the kitchen personnel with their bare hands.


The gasket surrounding the refrigerator door was covered in a black substance. Patient food was being stored in the refrigerator.


A rolling rack where patient food items were stored did not have a solid surface on the bottom shelve that would prevent mop water from contaminating the food items. The lower shelve had a buildup of dust and dirt. The rack had the appearance of being dirty and was unsanitary.


The food carts (hot and cold carts (service line) were not being moved and the floor under them was not being cleaned and sanitized. The food service line carts had a buildup of dust and food under them. The food service line carts' wheels were not being maintained. The wheels were covered in rust and what appeared to be dust and grease.


The hospital representatives were asked to move one of the food service carts. Staff struggled with the cart to get it to roll. This is the floor under the cart was discolored compared to the floor that had been mopped.


The air return vents in the patients' dining room were covered with black substance. These air return vents were located high, close to the ceiling. The ceiling above each of these vents was covered with black circular stains. Some of these stains were spots and some measured up to 3 and 4 inches across. These black circular stains extended to the center of the dining room.


A review of a document provided to the facility by an environmental consultants company revealed "Pursuant to your recent request, the" Company #1 "is pleased to provide the following proposal for professional environmental/industrial hygiene consulting services to be performed at the above referenced facility" (Building 509 &510). "The following package of environmental services is designed to evaluate the quality of indoor air in relation to mold at the subject property."

An interview on 10/20/2015, with Staff #11 revealed, these stains were reported to the Dietary Supervisor, staff #6. The stains were cleaned but quickly returned.

An interview on 10/20/2015, with Staff #10 revealed, the stains were dust and dirt caused by dirty air ducts and the entire air duct system would have to cleaned to stop the staining.

An interview on 10/20/2015, with Staff #9 about the stains being caused by dust and dirt from a dirty duct system. The question was raised, why there was no evidence of dust and dirt on the ceiling but instead there were these mysterious black circular patterns. Staff #9 revealed there was cause for concern and there was a need for an air quality study.

An interview on 10/20/2015, with the administrative staff and maintenance staff #1, #2, #3, #4, #5, #7, #8, and #10, revealed, they had knowledge of a potential mold problem in the building. The concern was so great that a common shower area was closed because of mold. The Governing Body was made aware of the problem and risk to patients on 09/15/2015. As of 10/20/2015, the Governing Body had not acted on behalf of the patients' safety and approved the funding for a requested air quality test and surface testing of building 509 and 510.

Based on observation, document review, and interview, the facility failed to maintain the building to provide a safe environment for patients receiving care at this facility. The facility had knowledge that buildings 509 and 510 having a potential mold problem and delayed the resolution of the problem. Patients (residents) continue to occupy and live and receive their meals in these buildings.

A tour of the patient dining room, food prep-area and food service area located in San Jacinto Unit (building 509 and 510), on 10/20/2015, was conducted with administrative staff and maintenance staff #1, #2, #3, #4, #5, #7, #8, and #10. During the tour the following were observed:

A black substance was observed around the dishwasher. The black substance had stained the once white caulk where the dishwasher met the wall. Staff #11 and #12 stated they had tried all the cleaners on hand including bleach. The black substance would fade to a lighter color but would quickly return to the black color that was observed.


The handwashing sink located in the food prep-area had a black substance that had stained the once white caulk where the sink met the wall. The foot operated water control paddles for the handwashing sink was covered with dust, dirt, and a black substance. The paddles had the appearance of not being cleaned.


A black, sticky looking substance was observed inside of the icemaker. This machine produced ice for patient use. Staff #7 and #9 were shown the black, sticky looking substance in the ice machine and confirmed the machine was in need of cleaning and disinfected.


The handles on the cabinets in the food prep-area had a buildup of a black crusty residue leaving the handles unsanitary. Food supplies were being stored in these cabinets. These cabinets were frequently accessed by the kitchen personnel with their bare hands.


The pulls handles for opening the drawers in the food prep-area had a buildup of a black crusty residue leaving the handles unsanitary. Food supplies and food serving utensils were being stored in these drawers. These drawers were frequently accessed by the kitchen personnel with their bare hands


The gasket surrounding the refrigerator door was covered in a black substance. Patient food was being stored in the refrigerator.


A rolling rack where patient food items were stored did not have a solid surface on the bottom shelf that would prevent mop water from contaminating the food items. The lower shelf had a buildup of dust and dirt. The rack had the appearance of being dirty and was unsanitary.


The food carts (hot and cold carts (service line) were not being moved and the floor under them was not being cleaned and sanitized. The food service line carts had a buildup of dust and food under them. The wheels of the food service line carts were not being maintained. The wheels were covered in rust and what appeared to be dust and grease.


The hospital representatives were asked to move one of the food service carts. Staff struggled with the cart to get it to roll. The floor under the cart was discolored compared to the floor that had been mopped.


The air return vents in the patients' dining room were covered with black substance. These air return vents were located high, close to the ceiling. The ceiling above each of these vents was covered with black circular stains. Some of these stains were spots and some measured up to 3 and 4 inches across. These black circular stains extended to the center of the dining room.


A review of a document provided to the facility by an environmental consultants company revealed "Pursuant to your recent request, the (Company #1) is pleased to provide the following proposal for professional environmental/industrial hygiene consulting services to be performed at the above referenced facility" (Building 509 &510). "The following package of environmental services is designed to evaluate the quality of indoor air in relation to mold at the subject property."

An interview on 10/20/2015, with Staff #11 revealed, these stains were reported to the Dietary Supervisor, staff #6. The stains were cleaned but quickly returned.

An interview on 10/20/2015, with Staff #10 revealed, the stains were dust and dirt caused by dirty air ducts and the entire air duct system would have to be cleaned to stop the staining.

An interview on 10/20/2015, with Staff #9 about the stains being caused by dust and dirt from a dirty duct system. The question was raised, why there was no evidence of dust and dirt on the ceiling but instead there were these mysterious black circular patterns. Staff #9 revealed there was cause for concern and there was a need for an air quality study.

An interview on 10/20/2015, with the administrative staff and maintenance staff #1, #2, #3, #4, #5, #7, #8, and #10 revealed they had knowledge of a potential mold problem in the building. The concern was so great that a common shower area was closed because of mold. The Governing Body was made aware of the problem and risk to patients on 09/15/2015. As of 10/20/2015, the Governing Body had not acted on behalf of the patients' safety and approved the funding for a requested air quality test and surface testing of building 509 and 510.

Based on observation, document review, and interview, the facility failed to provide a sanitary environment for the preparation and serving of food to the patients at the facility. The dining area where patients consume their food was potentially contaminated with mold and the facility delayed the evaluation, testing and possible need for cleaning of the environment. Patients continue to use this dining room.

A tour of the patient dining room, food prep-area and food service area located in San Jacinto Unit (building 509 and 510), on 10/20/2015, was conducted with administrative staff and maintenance staff #1, #2, #3, #4, #5, #7, #8, and #10. During the tour the following were observed:

A black substance was observed around the dishwasher. The black substance had stained the once white calk where the dishwasher met the wall. Staff #11 and #12 stated they had tried all the cleaners on hand including bleach. The black substance would fade to a lighter color but would quickly return to the black color that was observed.


The handwashing sink located in the food prep-area had a black substance that had stained the once white calk where the sink met the wall. The foot operated water control paddles for the handwashing sink was covered with dust, dirt and a black substance. The paddles' had the appearance of not being cleaned.


A black, sticky looking substance was observed inside of the icemaker. This machine produced ice for patient use. Staff #7 and #9 were shown the black, sticky looking substance in the ice machine and confirmed the machine was in need of cleaning and disinfected.


The handles on the cabinets in the food prep-area had a buildup of a black crusty residue leaving the handles unsanitary. Food supplies were being stored in these cabinets. These cabinets were frequently accessed by the kitchen personnel with their bare hands.


The pulls handles for opening the drawers in the food prep-area had a buildup of a black crusty residue leaving the handles unsanitary. Food supplies and food serving utensils were being stored in these drawers. These drawers were frequently accessed by the kitchen personnel with their bare hands.


The gasket surrounding the refrigerator door was covered in a black substance. Patient food was being stored in the refrigerator.


A rolling rack where patient food items were stored did not have a solid surface on the bottom shelf that would prevent mop water from contaminating the food items. The lower shelve had a buildup of dust, dirt. The rack had the appearance of being dirty and was unsanitary.


The food carts (hot and cold carts (service line) were not being moved and the floor under them was not being cleaned and sanitized. The food service line carts had a buildup of dust and food under them. The food service line carts' wheels were not being maintained. The wheels were covered in rust and what appeared to be dust and grease.


The hospital representatives were asked to move one of the food service carts. Staff struggled with the cart to get it to roll. The floor under the cart was discolored compared to the floor that had been mopped.


The air return vents in the patients' dining room were covered in a black substance. These air return vents were located high, close to the ceiling. The ceiling above each of these vents was covered in black circular stains. Some of these stains were spots and some measured up to 3 and 4 inches across. These black circular stains extended to the center of the dining room.


An interview on 10/20/2015 with Staff #11 revealed, the stains were reported to the Dietary supervisor. The stains were cleaned but quickly returned.

An interview on 10/20/2015, with Staff #10 revealed, the stains were dust and dirt caused by dirty air ducts and the entire air duct system would have to be cleaned to stop the staining.

An interview on 10/20/2015, with Staff #9 about the stains being caused by dust and dirt from a dirty duct system. The question was raised, why there was no evidence of dust and dirt on the ceiling but instead there were these mysterious black circular patterns. Staff #9 revealed there was cause for concern and there was a need for an air quality study.

An interview on 10/20/2015, with the administrative staff and maintenance staff #1, #2, #3, #4, #5, #7, #8, and #10 revealed, they had knowledge of there being a potential mold problem in the building. The concern was so great that a common shower area was closed because of mold. The Governing Body was made aware of the problem and risk to patients on 09/15/2015. As of 10/20/2015, the Governing Body had not acted on behalf of the patients' safety and approved the funding for a requested air quality test and surface testing of building 509 and 510.