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Based on observations and staff interview, the facility did not maintain a sanitary environment in the food service department. Findings included:

1. The food service department was inspected on 5/21/12 at 1:30 p.m. The dietary manager attended the inspection. The following concerns were noted:

- The stovetop burners and stove surfaces had a heavy accumulation of grease, burnt food and debris.
- Large spice containers of oregano (2.5 #), Pepper (5#), and garlic (7.25 #), were greasy to the touch with visible dust and dried food particles.
- The top of the dish machine had an accumulation of dust and food particles.
- The deep fryer had a layer of liquid grease visible behind the machine.
- The gas lines/pipes to the range/stove had a heavy accumulation of grease and debris and food particles were visible on the floor between the two cook stoves.
- The rinse sink in the dish room did not have an airgap fixture to prevent possible backflow into this sink. On 5/22/12 at 3:30 p.m., cookware was soaking in this rinse sink.¹

2. On 5/23/12 at 2:30 p.m. the dietary manager stated that she added the cleaning of the gas lines to the cleaning schedules.

¹ "There may not be a direct connection between the sewerage system and any drains originating from equipment in which food, portable equipment, or utensils are placed."
Food and Drug Standards title 37; Chapter 110, subchapter 2; Food Service Establishments, page 33; 37.110.219 - Plumbing, #3 & #6.

Based on record reviews and policy and staff interviews, the facility failed to ensure 5 (#s 14, 15, 16, 17, and 18) of 26 sampled records were complete. Findings included:

During the review of closed critical access patient records on 5/22/12 beginning at 9:15 a.m., the surveyor noted the following incomplete records:

1. Patient #14, a 86 year old female, was admitted to the swing bed on 4/27/12. The following required documentation lacked dates and times:
-Important Message from Medicare;
-Consent for Treatment form; and
-Admission Information for skilled Swing Bed Care.

2. Patient #15, a 42 year old male, was admitted to the swing bed room on 5/11/12. The following required documentation lacked date and time:
-Consent for Treatment form.

3. Patient #16, a 81 year old female, was admitted to a swing bed on 3/31/12. The following required documentation lacked dates and times:
-Consent for Treatment form;
-Patient Financial Responsibility; and
-Swing Bed Nursing Admit Assessment.

4. Patient #17, a 99 year old female, was admitted to a swing bed on 3/26/12 and discharged on 4/14/12. The Patient Discharge Instruction sheet lacked documentation of the time. Review of the physician's order documented that the patient was discharged on 10/14/12 instead of 4/14/12.

5. Patient #18, a 54 year old female, was admitted to a swing bed on 1/31/12 and discharged on 3/7/12. The following required documentation lacked dates and times:
-The swing Bed admission Contract;
-Important Message from Medicare about your rights; and
-Consent for Treatment form.

On 5/22/12 at 7:30 a.m., staff member A stated that all entries in the medical chart should include times, dates and signatures.

According to the Charting Nursing policy, reviewed on 5/22/12 at 3:00 p.m., documentation of all entries into the medical record are to have dates, times, and signatures.

Based on record review and staff interview, the facility failed to ensure that the clinical records for 16 (#s 2, 6, 7, 8, 9, 10, 11, 12, 13, 20, 21, 22, 23, 24, 25, and 26) of 26 reviewed records included complete and authenticated consent forms and assessment of health status. Findings included:

1. Patient #11 presented to the emergency department for treatment on 5/21/12. The facility's consent for treatment form did not include the time when the consent for treatment was obtained.

2. Patient #12 presented to the emergency department for treatment on 5/21/12. The facility's consent for treatment form did not include the time when the consent for treatment was obtained.

3. Patient #13 presented to the emergency department for treatment on 5/21/12. The facility's consent for treatment form did not include the time when the consent for treatment was obtained.

4. Patient #20 presented to the emergency department for treatment on 3/12/11. The facility consent for treatment form did not include a date, time or signature of when the consent for treatment was obtained.

5. Patient #21 presented to the emergency department for treatment on 3/1/11. The facility's consent for treatment form did not include a date, time or signature of when the consent for treatment was obtained.

6. Patient #22 presented to the emergency department for treatment on 6/5/11. The facility's consent for treatment form did not include a date, time or signature of when the consent for treatment was obtained.

7. Patient #23 presented to the emergency department for treatment on 3/21/11. The facility's consent for treatment form did not include a date or time of when the consent for treatment was obtained.

8. Patient #24 presented to the emergency department for treatment on 4/25/11. The facility's consent for treatment form did not include a date or time of when the consent for treatment was obtained.

9. Patient #25 presented to the emergency department for treatment on 3/30/11. The facility consent for treatment form did not include a date or time of when the consent for treatment was obtained.

10. Patient #26 presented to the emergency department for treatment on 6/30/11. The facility's consent for treatment form did not include a signature, date, or time of when the consent for treatment was obtained.


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11. Patient #2 was admitted to the facility on 5/21/12 for a vaginal hysterectomy. The patient was on Metformin 1000 milligrams twice a day for diabetes mellitus management.

A Nursing Admission Database was completed on 5/21/12. The clinician did not complete the Nutrition Screening portion of the assessment.

On 5/23/12 at 10:15 a.m., the closed medical record was reviewed and the Nutrition Screening remained blank.


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12. Patient #6 was admitted to the facility on 05/20/12 to the OB unit in active labor.

On 05/21/12 at 1:30 p.m., the open medical record was reviewed, and the facility's Consent form NS-1256, which included but not limited to, consent for hospital services and patient rights and responsibilities, did not include patient signature nor date and time when the consent was signed.

13. Patient #9 was born at the facility on on 05/20/12.

On 05/21/12 at 2:00 p.m., the open medical record was reviewed. The facility's Consent form NS-1256, which included, but not limited to, consent for hospital services and patient rights and responsibilities, did not include a patient representative signature nor date and time when the consent was signed.

14. Patient #7 was admitted to the facility through the emergency department on 04/30/12 for emergency irrigation and debridement of a right arm wound. No current medications were noted.

On 05/23/12, at approximately 11:00 a.m., the closed medical record was reviewed. The facility's Consent form NS-1256, which included, but not limited to, consent for hospital services and patient rights and responsibilities, did not include date and time when the consent was signed. The ER physician Orders form #SJH 145, was not dated and timed by the physician.

15. Resident #8 was admitted to the facility on 02/23/12 for dental restorations.

On 05/22/12 at 3:00 p.m., the closed medical record was reviewed. The facility's Consent form NS-1256, which included, but not limited to, consent for hospital services and patient rights and responsibilities, did not include a date and time when the consent was signed by the patient representative. The Authorization for Anesthesia form, #SJH 65006, was not dated and timed by the witness. The pre-operative instructions, form #SJH 63037, was not signed, dated and timed by the responsible party..

16. Resident #10 was admitted to the facility on 04/24/12 for labor and delivery of infant with fetal anomalies, which resulted in fetal demise.

On 05/23/12 at 8:00 a.m., the closed medical record was reviewed. The facility's patient discharge instructions form, #SJH 50, was not signed, dated or timed, by the patient or the discharge nurse.

Based on observation and staff interview, the facility failed to ensure that clinical records were safeguarded against loss, destruction, or unauthorized access. The findings included:

On 5/22/12 at 2:00 p.m., the surveyor observed the medical record department. The medical records were stored on several wooden shelves. The shelf units were located directly under the automatic fire sprinkler system. The shelf units were open and did not have doors or covers. The medical records were at risk for water damage if the sprinkler system was triggered by a fire.

At this time, the medical record manager stated that she was not aware that the medical records needed to be protected from loss or destruction. The wooden cabinets were made for the department and were not fire proof and the open shelves would not protect the medical records from damage.