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Based on record review and staff interview, it was determined that the facility failed to properly organize the medical record in a manner that prevents another clients information from being filed into the record. This was evident for 1 of 14 sampled open medical records reviewed. The findings include:
On March 14, 2011 at 10:45 a.m., surveyor review of medical record for client #2 revealed that 3 pages of client #1's preadmission information dated 02/07/2011 was stapled to the back of client #2's preadmission assessment also dated 02/07/2011. This concern was discussed with the nursing staff including the Chief Nursing Executive and the paperwork was subsequently filed in the correct medical record.

Based on a review of 15 closed medical records, one record was identified that had a discharge summary signed more than 30 days post-discharge.

Medical record #3 was an infant admitted on December 27, 2010 and discharged on January 17, 2011. The discharge summary was not signed until March 9, 2011

Based on the observations during a tour of the facility it was determined that the food service director must address the following identified food service sanitation and storage problems as noted below:
At 9:30 AM on March 14, 2011, the surveyor toured the kitchen accompanied by the dietary assistant manager and the maintenance director.
The following observations were made:
One employee was washing dishes in the dishwasher, responsible for handling both clean and unclean dishes. The nearest hand sink was located by the cooking equipment, and access was blocked by a rack of dishes that was corrected when the surveyor identified the blocked handsink.
Cereals and grits were stored opened with labels on the rack to the left of the cooking equipment.
A wet mop was observed sitting in a mop bucket adjacent to the dishwasher. The hangers for brooms were installed over a dry area of the floor and not a drain, making them inappropriate for dripping mops. Mops should be hung to air dry to avoid providing a water source for vermin.
A non- commercial refrigeration unit in the kitchen was being used for storage of patient foods. The refrigerator was labeled "Employee use Only." The surveyor was told by the assistant food service director that the unit is only used for patient foods and she was unaware of why the label was on the refrigerator. There was no thermometer present that would allow staff to quickly check to see if the temperature was within acceptable limits. There was an electronic thermometer that is remotely monitored. Non commercial refrigeration is not approved for patient food storage.
Numerous items in the walk in refrigerator were not dated. Approximately 10 pounds of cheese, sliced by facility staff, was observed without the original packaging or any information about date opened or discard date.
Cooked, shelled hard boiled eggs were stored uncovered on a lower shelf in the walk in refrigerator The lid for their container was missing and a ladle was stored in the container. Refrigerated foods must be protected from potential contamination.
The internal thermometer for the two-door freezer near the cook line registered 18 degrees Fahrenheit on March 14, 2011. The maximum allowable temperature for frozen food storage is 0 degrees F, with exceptions for short periods of a few degrees higher during peak use such as meal times. The foods were frozen solid and no dripping was observed. The assistant dietary manager stated that the temperatures are monitored electronically but could not explain how the system notified staff of out-of-range temperature, or what interventions would be taken in the event of out-of-range temperatures. On March 15, 2011, interview of the dietary manager and record review from the monitoring company showed that the unit had been documented at 0.9 to 12 degrees Fahrenheit since March 1, 2011. No interventions had taken place to rectify the situation. Further review of the record showed that the alarm thresholds were set to alarm at plus or minus 25 degrees Fahrenheit. ( Cross referenced to A724)
On March 14, 2011 at 9:45 AM and March 15, 2011, at 10:00 AM, sanitizer was not available in tubs for wiping cloths. On March 14, 2011 a soiled wiping cloth was observe sitting on a cutting board being used for slicing food.
Hamburger buns were stored in the grill food service area four to five inches from the hand sink. Foods should not be stored within 12 inches of a hand sink to prevent soiled water from splashing onto the food.
In addition, the following was noted during a tour of a remote nursing unit located within another hospital: An administrator and the surveyor toured the family lounge. The family lounge contains a small refrigerator that the Administrator said was managed by the patients' families. The refrigerator contained a thermometer, unlabeled food wrapped in plastic wrap, and a few other food items. When the surveyor asked for the temperature log, the Administrator reiterated that the "Families take care of the refrigerator," and that staff do not clean the family refrigerator or monitor the refrigerator temperatures in either the family or the employee refrigerator. Since there is nothing preventing the storage of patient food in the family refrigerator, staff should, at a minimum, be monitoring the temperatures.

Based on observations made during the Life Safety Code survey on April , 2011 it was determined that the Condition of Participation for the Physical Environment was not met as result of the lack of warning signage in oxygen storage areas as noted at K0076 ; isolated penetrations between floors and damaged fireproofing cited at K0012; needed adjustments to the coordinating devices on fire doors cited at K0021; maintenance problems at exit doors cited at K0038; the lack of exit door signage at two doors cited at K0046; and sprinkler system maintenance cited at K0056.

Based on observations and staff interview, it was determined that the facility failed to ensure that parts of the physical environment were maintained is a manner to ensure the safety and well-being of patients and families.
On a tour of the facility with the facilities manager on March 14 and 15, 2011, the following were noted:
The fire doors at the entrance to the Rehabilitation and Cafeteria and Vending area did not close as required when released. A coordinator (device used to ensure the doors close in proper order in case of fire) installed at the top of the door jamb was blocking the complete closure of the doors. Per interview of the maintenance director, the coordinator was out of adjustment. These doors must close and securely latch in the event of a fire to reduce smoke and fire spread.
On March 15, 2011 at 10:45 a.m., the surveyor, along with the Occupational Therapy Manager observed that the soiled linen cart in Feeding Room E1-113 had brown debris on the top of the lid. Further review of Feeding Room E1-118, 5 minutes later revealed a large amount of food debris on the top and sides of the lid, which appeared to have accumulated over a long period of time.
In the basement of the building, fire corridors were blocked with rolling trash containers and equipment that was stored against the wall. Corridors leading to an emergency exit may not be blocked.
Holes and missing ceiling tiles were observed in the ceiling above a tank for the fire suppression system and the dishwasher.
The exhaust hoods above the cooking equipment in the main and auxiliary kitchens had not been serviced since March 2010, one year ago. Review of documentation from the vendor who provides cleaning service showed that the recommendation for cleaning for both hoods was every six months, due in September 2010, making the cleaning overdue by over five months.
Lights servicing the exhaust hood for the cooking equipment were not functioning.
The caulk sealing the dishwasher to the adjacent wall was not smooth and had visible mold.
A wet mop was observed sitting in a mop bucket adjacent to the dishwasher. The hangers for brooms were installed over a dry area of the floor and not a drain, making them inappropriate for dripping mops. Mops should be hung to air dry to avoid providing a water source for vermin.
A shelf was installed over the stove was unclean and greasy. The location of the shelf was conducive to grease and soil collection and for condensation from cooking to drip back into foods on the stove. The shelf was removed during the survey.
A non commercial refrigeration unit in the kitchen was being used for storage of patient foods. The refrigerator was labeled " Employee use Only " The surveyor was told by the assistant food service director that the unit is only used for patient foods and she was unaware of why the label was on the refrigerator. There was no internal thermometer except the device used by the electronic monitoring system to ensure that staff could quickly see if the temperature of the unit was adequate. Non commercial refrigeration is not approved for patient food storage.
An administrator and a surveyor toured the family lounge in an ancillary nursing unit contained within another hospital on March 14, 2011. The family lounge contained a small refrigerator that the Administrator said was managed by the patient's families. The refrigerator contained a thermometer, unlabeled food wrapped in plastic wrap, and a few other food items. When the surveyor asked for the temperature log, the Administrator reiterated that the " Families take care of the refrigerator, " and that staff do not clean the family refrigerator or monitor the refrigerator temperatures in either the family or the employee refrigerator. Since there is nothing physically preventing the storage of patient food in the family refrigerator, staff should, at a minimum, be monitoring the temperatures.


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Based on a tour of the kitchen it was determined that a freestanding freezer was not holding temperature within the required range as evidenced by :
During a tour of the kitchen it was observed that the internal thermometer for the two-door freezer near the cook line registered 18 degrees Fahrenheit on March 14, 2011. The maximum allowable temperature for frozen food storage is 0 degrees F, with exceptions for short periods of a few degrees higher during peak use such as meal times. The foods were frozen solid and no dripping was observed. The assistant dietary manager stated that the temperatures are monitored electronically but could not explain how the system notified staff of out-of-range temperature, or what interventions would be taken in the event of out-of-range temperatures. On March 15, 2011, interview of the dietary manager and record review from the monitoring company showed that the unit had been documented at 0.9 to 12 degrees Fahrenheit since March 1, 2011. No interventions had taken place to rectify the situation. Further review of the record showed that the alarm thresholds were set to alarm at plus or minus 25 degrees Fahrenheit.