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Based on record review and interview, the facility failed to ensure that patient medical records were completed, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the services provided; and in accordance with the facility's policies and procedures for 3 of 20 patient records reviewed (Patient #4, #9 and #10).

Findings included:


Record review of Patient #4's medical record, date of admission 1/24/23, revealed the Admission and Notice of Privacy form was missing from the medical record.

Record review of Patient #9's Medical record, date of admission 2/8/23, the Notice of Privacy Practices Acknowledgment was signed by the patient, but was not dated.

Record review of Patient #10's Medical record, date of admission 3/20/23 revealed the Documentation of Informed Consent for Operative and Other Invasive Procedures and Informed Consent for Anesthesia was signed and dated by the attending Physician, but was not timed.

Interview on 7/17/23 at 2:45 PM with Facility Staff #8 confirmed the above records were incomplete, undated, untimed, and not authenticated in written or electronic form by the person responsible for providing or evaluating the services provided.

Record review of the facility policy, titled, Consent to Treatment Policy, last revised 3/23, states in part ...Before any medical or nursing care is rendered or before any medical or surgical procedure is undertaken, consent to such care or treatment must be obtained from the patient or someone authorized to consent for him/her.

Based on observation, interview, and record review, the facility failed ensure that food and dietetic services organization requirements were met and; in accordance with the facility's polices. Specifically, The Director of Food Services failed to ensure:

1.) Food intended for patient use was properly stored, labeled, and dated.
2.) Expired food was discarded and not available for use.

This deficient practice could place the Patients and employees at risk of obtaining food borne illnesses and/or infections.

Findings included:

Observations conducted on 7/17/23 at 1:50 PM of the facility's Dietary Department with the Director of Food Services (DFS) present revealed the following:

In the freezer there were multiple plastic bags of different foods that were removed from their original packaging that were not labeled with the food item or dated. It was unknown how old the plastic bags of food were.

The DFS stated during the observations on 7/17/23 at 1:50 PM that some of the bags that were not labeled were chicken thighs. The DFS confirmed the frozen foods had been removed from their original packaging and did not contain a label with the food item or dated.

*Open bag of whole green beans that were not labeled when opened or when expired.

In the dry storage room, the following was observed:

*Plastic bag of coconut that had an orange label with an expiration date of 4/6/23. The orange label contained the product name, today's date, today's time, the expiration date, and initials.

*Container of vanilla wafers that had an orange label with an expiration date of 5-18 (no year).

*Bag of vanilla wafers that had an orange label with an expiration date of 6/27/23.

Interview with the DFS during the observations on 7/17/23 at 1:50PM confirmed the vanilla wafers and coconut were expired according to their orange labels and should not be available for use.

*Plastic container with individually wrapped saltine crackers. The bin did not contain any label with an expiration date.

*Plastic container labeled, Macaroni. There was not an expiration date or an orange label. There were 3 separate white labels that were all labeled "12/27/19". There were another 3 labels that were placed on top of each other that appeared to have "SEP 21 21." The label was not readable.

*Plastic container that contained individual serving packets of Fat Free Ranch dressing. There was not an expiration date or an orange label. There were four separate white labels that were all labeled, "10/29/19." There were another 2 labels that were not readable, they appeared to be Oct 19- 21. The Ranch dressing packets did not have expiration dates imprinted on the individual packets.

*Container of individual servings of Cheerios cereal. The container had multiple labels on the outside; received 06-17, received Mar 3-22, received Sep 30-22 and received Feb 10-23. The cheerios cereal containers did not contain expiration dates imprinted on the individual containers.

*Container of individual servings of Raisin Bran cereal. The container had a white label sticker that had "received Sep 6-22." The Raisin Bran cereal containers did not contain expiration dates imprinted on the individual containers.

Interview with the DFS during the observations on 7/17/23 at 1:50 PM stated the white labels were the dates the food was "received". The DFS confirmed the above foods did not contain any labels that indicated when the food was opened or when expired. The DFS stated there were multiple receive dates on the plastic containers because items were received at different times.

*On a rack in the kitchen were two loaves of bread in a clear plastic bag that did not contain any dates or labels. There was a clear plastic bag with hamburger buns that did not contain a label or date. There was a clear plastic bag of rolls that did not contain a label or date.

Review of the contracted policies and procedures revealed the following:
Food and Supply Storage, last reviewed 08/2022 indicated in part,
General Storage Practices:
*Cover, label, and date unused portions and open packages. Use the [contracted] Culinary and Nutrition orange label; complete all sections on the label.
*Discard food past the use-by or expiration date.

Based on observation, interview, and record review the facility failed to provide a clean, sanitary, and safe environment to avoid sources and transmission of infections and communicable diseases.

Specifically, observations of the facility revealed the following:

1.) The Medical Surgical area was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases.

2.) The Post Anesthesia Care Unit (PACU) area was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases.

3.) The Emergency Department (ED) area was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases.

4.) The Newborn Nursery area was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases.

5.) The CAT-Scan area was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases.

6.) The Cardiopulmonary area was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases.

7.) The Physical (PT) area was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases.

8.) The Retail Service Line in the kitchen area was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases.


These deficient practices placed the patients' health and safety at risk for the transmission of infections and/or communicable diseases.


Findings included:

Observations on 7/17/23 at 1:00 PM of the facility with facility staff # 2 and #3 revealed the following:

1.) Med/Surg
In medication room, plastic bins that stored needles and saline flushes was dirty in the bottom of the bins.

Open 2x2 gauze was stored in the plastic bin, not individually wrapped.

Tape residue on the plastic bins, not a wipeable surface.

Exam Room, holes in the wall behind the monitor, not a wipeable surface.

Bedside table was dusty on the top surface.

The Computer On Wheels (COW) had a dusty base.

The handwashing sink at the nurses station had calcium/lime deposit build up around the faucet nozzle.


2.) PACU
Entering the PACU, the light switch plate had a small, not sealed gap between the plastic light switch plate and the drywall.

Recovery room 1, Office supplies were mixed with medical supplies in the drawer.

Ice maker had calcium/lime deposit build up on the base of the ice maker machine.

The hand washing sink, the caulking around sink, against the wall, was not longer sealed, exposing open gaps.


3.) ED
A.) An infant scale was dusty on the bottom shelf.

B.) Triage Area Vital Sign machine was dusty on the base.

C.) Ice maker had calcium/lime deposit build up on the base of the ice maker machine.

The handwashing sink at the medication counter had calcium/lime deposit build up around the faucet nozzle and basin of the sink.

Two sharps containers in the medication area, had the tops off, leaving the opening wide open for hands to enter.


4.) Newborn Nursery

The handwashing sink had calcium/lime deposit build up around the faucet nozzle and basin of the sink.

Opening the cabinet under the handwashing sink, revealed it to be dirty.


Further observations of the facility on 7/18/23 revealed the following:


5.) CAT-Scan
A.) Opening the cabinet under the handwashing sink, revealed it to be dirty, dusty, and stained with what looked like water damage.


6.) Cardiopulmonary
The hand washing sink, the caulking around sink, against the wall, was not longer sealed, exposing open gaps. Brown stains around the worn out caulk.


7.) Physical Therapy
At the weight station, there was a vinyl seat that was covered in tape. The edges of the tape were curling up. This was an un wipeable surface.


8.) Retail Service Line in the kitchen
A.) The overhead drop lighting over the serving line had a buildup of dust.

B.) The grills on the Air condition vents and return vents in the retail service area, have a buildup of dark brown substance that was consistent with dirt.


Interviews on 7/17/23 – 7/18/23 at the time of the observations with Facility Staff #2 and #3 confirmed all the above findings.

Interview on 07/18/23 at 1210 pm with Facility staff #17 revealed that the kitchen staff is not responsible for cleaning the Air conditioning and return vents in the retail service line area. Staff also stated that the drop lighting would be too high for the kitchen staff to reach but confirmed that the lights and vents were dirty. She stated she would consult with the staff in the hospital responsible for cleaning them to get it done.

Interview on 07/18/23 at 1220 pm with Facility staff #2 revealed that she was not aware of the problems with the Air conditioning and return vents in the retail service line area or the drop lighting. She states that these areas should be cleaned by the facility cleaning staff every 30 days or sooner if needed. She reached out to the responsible staff, and they would clean it today as soon as the area closed for service, and they would ensure it was put on the schedule for monthly cleaning.


Record review of the facility policy, titled Cleaning, Disinfecting and Maintaining Equipment, revision date 3/2022, states in part ....

-Clean and disinfect the entire surface area – top to bottom-, inside and out (T.B.I.O.)

-If equipment has removable parts, such as filters, pad drivers, or debris trays, remove the part and clean and disinfect.