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Based on observation, staff interview, and review of facility documents, it was determined that the Governing Body failed to demonstrate that it is effective in carrying out the operation and management of the facility. The Governing Body failed to provide necessary oversight and leadership as evidenced by the lack of compliance with the following Condition of Participation:

482.28: Food and Dietetic Services

Based on observation and staff interview conducted on 10/19/18, it was determined that the facility failed to ensure compliance with Federal and State licensure requirements for food and dietary personnel as well as food service standards, laws and regulations.

Findings include:

1. The facility failed to ensure that the Director of Food & Nutrition Services provided effective daily management of the Food Service Department in accordance with Federal, State, and Local Regulations.
(Refer to Tag A620)

Based on observation during a tour of the main kitchen, review of facility documents, the New Jersey State Sanitary Code, Sanitation in Retail Food Establishments and Food and Beverage Vending Machines (N.J.A.C. 8:24), and patient and staff interviews, conducted on 10/19/18, it was determined that the Food Services Director failed to ensure responsibility for the daily management of the Food Services Department.

Findings include:

Reference #1: Food Service Director job description and performance appraisal, states, "...I. 4. Creates a culture of Patient Safety and Continuous Improvement that contributes to providing quality services that are safe and cost effective...III 4. Ensures all aspects of departmental operations including but not limited to patients services, Production, catering and Retail operations function in a manner that ensures patient and customer satisfaction as well as optimal efficiency and regulatory compliance..."

Reference #2: Executive Chef job description, states, "... 2b. Maintains a clean sanitary work areas as defined by departmental policy in conjunction with all regulatory agencies to ensure safe food handling practices and kitchen clean-up...2d. Use departmental guidelines for washing all food contact surfaces...2e. maintains storage areas using proper storeroom procedure. ..."

Reference #3: Staff Lead Cook job description, states, "... Assists in the overall sanitation of kitchen equipment...Coordinates with kitchen staff daily production and kitchen and all sanitation procedures are followed by kitchen staff...2b. Maintains a high level of sanitation..."

Reference #4: Facility policy, Personal Hygiene, states, "...b. Hair nets and/or caps worn at all times. ..."

Reference #5: Facility policy, Dating of Prepared Food, states, "...After preparation and placement into its serving container, an expiration date is assigned to the food product. ...6. Any food in storage after its expiration date is discarded. ..."

Reference #6: Facility policy, Grease and Trash Removal, states, "...Waste grease is placed in a 55 gallon drum with a tight cover provided by the rendered and kept in dish machine area. The Renderer removes the grease on a monthly basis. ...Management should contact renderer for pick up of full barrel. "

Reference #7, Facility survey, Location Kitchen/Cafe, Date: 7/10/18, states, "Environmental ... Floors, surfaces, trash cans, and furniture clean. Fail ..."

Reference #8: Facility policy titled, "Food Temperatures" states, "...1. All foods are prepared, served, and stored adhering to time and temperature principles and HACCP guidelines. ...2. The Meal Service Checklist is used to document food temperatures at each meal. ...3. Food temperatures are taken prior to start of meal service. Temperatures are checked periodically during meal service to ensure compliance.

Reference #9: N.J.A.C. 8:24-6.5(a) states, "The physical facilities shall be maintained in good repair."

Reference #10: N.J.A.C. 8:24-4.6(a) states, "Equipment food-contact surfaces and utensils shall be clean to sight and touch."

Reference #11: N.J.A.C. #8:24-6.5(b) states, "The physical facilities shall be cleaned as often as necessary to keep them clean."

Reference #12: N.J.A.C. 8:24-6.5(j) states, "The premises shall be free of items that are unnecessary to the operation or maintenance of the establishment such as equipment that is non-functional or no longer used, and litter."

Reference #13: N.J.A.C. 8:24-4.5(a) states, "The Equipment and equipment components shall be maintained in a state of repair and condition that meets the requirements specified under N.J.A.C. 8:24-4.1 and 4.2."

Reference #14: N.J.A.C. 8:24-2.4 (c) 1. states, "... food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils..."

Reference #15: N.J.A.C. 8:24-4.6 (a) states, "Equipment food-contact surfaces and utensils shall be clean to sight and touch. (b) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (c) Non food-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris."

Reference #16: N.J.A.C. 8:24-6.2(l) states, "Dead or trapped birds, insects, rodents, and other pests shall be removed from control devices and the premises at a frequency that prevents their accumulation, decomposition, or attraction of pests. ..."

1. During a tour of the main kitchen at approximately 9:30 AM, in the presence of Staff #1, Staff #2, Staff #4, and Staff #7, the following was observed: (Refer to references #1, #2 and #3)

a. Staff #6 and Staff #15 had facial hair and were not wearing beard guards while preparing lunch trays.

i. Staff #16 had waist length hair and failed to cover his/her hair completely. (Refer to references #4 and #14)

b. Two (2) tray line steam tables failed to have shield guards, causing possible contamination of food on the steam table.

i. Upon interview, Staff #5 states he/she was unsure of when the shield guards had broken or if a work order for repair, was placed. (Refer to references #9 and #13)

c. The refrigerators and freezers throughout the kitchen, did not have manual temperature measuring devices. (Refer to reference #8)

i. Staff #4 confirmed the above finding.

d. A microwave was located next to the deep fryers. The microwave was covered with visible debris and brown encrusted grease deposits. There was a large radio on top of the microwave. The radio had an antenna made from aluminum foil. The radio was visibly dirty and contained grease splashes. (Refer to reference #13)

i. Upon interview, Staff #6 stated that the microwave did not work.

ii. Staff #4 stated that the microwave should have been removed.

e. Three (3) packets of cheese were in the deli-cart refrigerator. The cheese packets were opened and rewrapped. The cheese was not labeled with expiration dates. (Refer to reference #5)

i. Upon interview, Staff #21 stated that he/she was unsure of when the cheese packets were opened.

ii. Upon interview, Staff #4 and Staff #6 were unable to explain the food labeling process.

f. The door gaskets were peeling on refrigerator #7, preventing the door from having a tight seal. (Refer to references #9 and #11)

g. Refrigerator #8 and #9 were visibly covered with a gray brown crusted substance. There was a grayish black substance on the gaskets, preventing the refrigerator doors from having a tight seal. (Refer to references #7, #8 and #11)

h. A walk in freezer, in the ware washing area, was labeled, "not in service." It was being used for storage. The freezer was filled with broken and unused equipment such as: stoves, fans, chairs, and refrigerators. The freezer walls were covered with a brown/black encrusted substance. A musty odor permeated throughout the freezer.(Refer to references #10 and #12)

i. The four (4) door convection oven in the cooking area, had broken door handles. The oven was covered with dirt and large deposits of dark brown discoloration and encrusted grease splashes. (Refer to references #7 and #9)

j. The lid for the convection oven was missing, therefore exposing electrical wiring.

i. Upon interview, Staff #4 stated he/she was unsure of how long the lid had been missing and was not able to confirm that a work order was placed to have the lid replaced. (Refer to references #7 and #9)

k. There was an extensive amount of grease deposits and dust debris on the side wall panel of the cooking area. (Refer to references #9, #10)

l. A dead mouse, in a mouse trap, was in the corner of the cooking area. (Refer to reference #16)

m. At 11:31 AM, food trays were placed in open food carts that were not insulated, therefore compromising food temperatures during transport of food trays to the units. (Refer to reference #8)

i. During a tour of the facility, upon interviewing patients, three (3) out of three (3) patients complained that their food was delivered cold.

ii. The temperature log used to record food temperatures during meal service had a column to record temperatures during the Mid-Point of meal service. The temperature log failed to have a Mid-point temperature logged for breakfast or lunch meals on 10/19/18.

o. Two (2), uncovered 55 gallon drums filled with used cooking grease were stored near the ware washing area, attracting fruit flies. (Refer to reference #6)

2. Upon interview, Staff #20, the Operations Manager of Environmental Services, stated he/she performed a survey of the main kitchen, on July 10, 2018. The kitchen failed for cleanliness. (Refer to reference #7)

i. Staff #20 stated he/she shared the outcome of the survey with the Food Service Director for follow up.

ii. There is no documented evidence that the Food Service Director addressed the failed outcome. (Refer to reference #1)

3. Staff #4 provided the local county sanitation report dated 5/1/18, which indicates deficiencies related to cleanliness of equipment and food left on the floor attracting rodents and fruit flies.

i. During interview, Staff #4, Staff #10, and Staff #11, stated that they were aware of the findings from the 5/1/18 sanitation report.

4. Upon request, Staff #4 was unable to provide Quality Assessment Performance Improvement data regarding cleanliness of the main kitchen.

i. Staff #11 stated that hospital administration was aware of the lack of management and oversight in the Food Service Department.