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Based on observation, interview, and record review, the facility failed to maintain the food services department in a organized and sanitary environment when,
- the dirty dustpan was hanging in a utility closet touching the light switch, staff had to touch the dustpan to turn the light on and off,
- the microwave had dried, dark brown, crusty food debris on the inside vents,
- the standing refrigerators outside temperature gauge was not working, it read less than -40 degrees Fahrenheit,
- (9) Styrofoam containers, filled with Jello, were not dated, or labeled,
- the steel shelving rails had rust, making them unable to be cleaned properly,
-(5) large white rolling food storage bins had dried, crusty food debris on the handle and lips and (3) had large plastic scoops inside the bins,
- An approximately 3 x 8-inch sticky insect trap was sitting on the floor next to the pot washing station, the trap had copious amounts of insects stuck to the mat, the mat had standing water in the mat; the insects were decomposing on the mat,
- the dirty dishes and pots were being stored next to clean dishware and pans, in two locations in the kitchen,
- the splash guards had dried food debris on (3) mats located around the kitchen and clean pans had food debris on them,
- a ½ gallon of Sweet & Sour sauce had been opened on 3/17/25, the jar had ¼ gallon of content missing. The manufacturer label read "REFRIGERATE AFTER OPENING"; the opened container was sitting on the bottom shelf in the food preparation area, not in the refrigerator,
- a 1-quart plastic container, unlabeled, filled with an unknown yellow substance, was located on the baker's rack shelving; the contents smelt like discarded lard,
- the facility's food processor's on and off buttons had dark, sticky food debris on the switches,
- the facility's food mixer had dried and flaking food debris on the undercarriage of the mixer, from previously mixed food products,
- the walk-in refrigerator's inner freezer door had food debris noted on the door,
- thawing, pork, beef, and turkey products had been removed from the original packaging; the items were not dated as to when they were placed in the refrigerator,
- the facility's milk crates were sitting on the walk-in floor, the floor had signs of dried milk residue, and
- (9) opened spices did not have a date when opened.

This failure places all patients, receiving food from the facility's kitchen, at risk of contracting a food born illness.

Findings include:

During the tour of the facility's dietary department on the morning of 4/28/25, Staff #4, Director of Food and Nutrition Services confirmed the findings and stated, "We have been working on cleaning up the kitchen."

During an interview, on 4/29/25 in the conference room, when asked if rounding the kitchen was part of the infection control program, Staff #6, Infection Control Nurse stated she had started 6 weeks ago and had not gone into the kitchen yet.

Review of the facility provided policy, "Food Labeling and Dating" (Revised 12/2019) reflected, All prepared foods and food stored out of the original container, are to be covered, labeled and dated ...9. Spices are labeled with an open date and expire 1 year after opening."

Review of the city of Mesquite food service Inspection dated March 21, 2025 reflected, the facility was out of compliance for Food contact surfaces and returnables; cleaned and Sanitized.

Review of the Texas Food Establishment Regulation Code (2024) reflected, "228.101(i)Nonfood-contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of a corrosion-resistant, nonabsorbent, and smooth material.
228.113(3)Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.
228.114(c)Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.

Based on observation, interview, and record review, the facility's Environment of Care committee (EOC) failed to develop and maintain an effective Environmental Rounds Program to recognize and effectively investigate and correct potentially hazardous situations when,
(1) The dishware washing hood vent had dark brown, dried drainage noted on the outside of the vent; the vent went up into the ceiling.
(2) The facility's food service department's floor was found to have numerous areas of cracked and missing grout, creating an unsanitary environment.
(3) The facility's cafeteria smelt of sewage, and the doorway between the dry storage area and the kitchen smelt of sewage on this day and two days prior; this had been reported the previous month and been recorded as completed.

Findings include:

Review of the facility provided policy "Environmental Tours: (revised 4/2022) reflected, "Procedure: The Program shall serve the dual purpose of identifying potentially hazardous situations ...b. specific concerns of Infection Control ...work orders will be created to correct deficiencies found and will serve as a tracking tool ..."

(1) An observation on the morning of 4/28/2025, in the facility's dish room revealed the dishware washing hood vent had an unidentified dark brown, dried drainage noted on the outside of the vent running down to the front of the machine.

During an interview on the morning of 4/30/2025, in the facility's dish room, Staff #45, Regional Director of Plant Operations confirmed the dark residue and stated in part it could be condensation.

(2) An observation of the facility's food service department on the morning of 4/28/2025 revealed numerous areas of missing grout to the kitchen's heavy traffic areas, there was black debris and dirt noted in the missing space. The interior wall to the walk-in refrigerator had a 3 x 2-inch piece of tile missing, the interior wall insulation was exposed and there was a yellow substance noted in the opening. The facility's wall boards were detached at points and the tile and baseboard were missing, where the tile leads to the outside of the kitchen back door; there was dirt and debris in the missing spaces.

(3) An observation of the facility's food service department on 4/28/25 at 12:30 pm reflected as strong odor of sewage in the facility's cafeteria.

An observation on 4/30/25 at 11:00 am, of the facility's cafeteria revealed a strong odor of sewage in the facility cafeteria. The connecting door led to a dry storage area containing paper products; there was no odor detected in the room. Through the next doorway, which led into small room, the sewage odor was emanating from a wall; there was no open drain in the room or obvious source of the smell.

Review of the facility's work order dated 3/17/25 reflected, location: Cafeteria, Short description: Odor, there is an odor coming from the wall in the storage room in the cafeteria. Resolution Detail: Check for smell. Result: Complete

During an interview on the afternoon of 4/30/25, while trying to locate the source of the odor, Staff #45, Regional Director of Plant Operations, confirmed the odors. Staff #46, Plant Operations Supervisor stated, "I will get someone right on it."

During an interview, on the afternoon of 4/30/25, Staff #46, Plant operations supervisor stated in part, when the staff put in a work order, he will assign a person to make the repairs. The plant operations person making the repair can close out the repair order, they can also put in additional repair orders if needed. When asked if the Plant operations conducts rounding to ensure the upkeep of the facility, Staff #46 said yes, but did not provide evidence of the rounding. Staff #46 stated, "We try to be proactive."

Review of the Texas Food Establishment Regulation Code (2024) reflected, 228.173(a)Cleanability. Floor, wall ceiling constructed installed are smooth and easily cleanable 228.173(f)(1) Wall and ceiling covering materials shall be attached so that they are easily cleanable, 228.186(a)Repairing. The physical facilities shall be maintained in good repair,228.149(e)(2)A plumbing system shall be maintained in good repair.

Based on observations, review of facility documents, and staff interviews, the facility failed to prevent and control infection transmission as noted in policies and procedures.

Findings were:

During a surgery observed on the afternoon of 4/29/25 of patient #15:
- staff #36, CRNA, did not wipe the tops of medication vials with 70% alcohol prior to drawing up the medication. Staff #36 then administered medications to the patient without cleaning the septum of the intravenous lines.
- staff #35, circulating registered nurse (RN), entered and exited the surgical suite multiple times without performing hand hygiene.
During tours of the radiology and laboratory departments on the morning of 4/28/25, the Operating Room and endoscopy suite on the afternoon of 4/29/25, and the labor and delivery unit on the morning of 4/30/25, dust was observed on both high and mid-level horizontal surfaces. These findings were verified by staff during each tour.

During a tour of the labor and delivery surgical area on the morning of 4/30/25 with Staff #48, Director L&D, two handwashing sinks were operating for several minutes without the water becoming warm. Staff #48 felt the water and verified the water was not warming.

Facility policy titled "Hand Hygiene (CDC [U.S. Center for Disease Control and Prevention] based)" last reviewed 03/2025 stated in part, "Purpose: Hand hygiene is the most important procedure for preventing infections and a top priority ...
Procedure:
1. Alcohol Based Hand Rub
1.1 Decontaminate hands using alcohol based hand rub in the following circumstances: ...g. After contact with inanimate objects (including medical equipment) in the patient room.
h. After removing gloves.
2. Hand Washing
2.1 Was hand with soap and water in under [sic] the following circumstances
d. As an alternative to alcohol based hand rub in any of the situations describes [sic] in 1, above."

Facility policy titled "Cleaning of Operating Rooms" last revised 04/2025 stated in part, "1. Damp dust all flat surfaces and overhead lights every morning prior to the first surgical procedure ...
3. All flat surfaces shall be cleaned first with an approved detergent germicide dampened disposable wipe."

Facility policy titled "Patient Room Cleaning" last reviewed 10/2020 stated in part, "4. Clean and disinfect room ... countertops, light switches, furniture, arm/seat of patient chairs, window sills [sic], beside [sic] commode, medical equipment, other miscellaneous surfaces."

Facility policy titled "Lobby and Waiting Area" last reviewed 10/2020 stated in part, "1. Daily: 1.1 High dust - use high duster. TV, ceiling vents, horizontal surfaces, window and door frames.
1.2 Damp Wipe - use disinfectant wipe. Table tops, counters, window sills [sic], spot wash walls, check under loose cushions, arrange magazines neatly, public phones ..."

In an interview on the afternoon of 4/29/25, staff #47, Director of Surgical Services, confirmed OR staff should be performing hand hygiene when entering and exiting the surgical suite and should be cleaning the tops of medication vials and IV ports prior to administering medications.

CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings found at https://www.cdc.gov/infection-control/hcp/core-practices/index.html Standard Precautions stated, in part, " ...Use aseptic technique when preparing and administering medications."

Open Resources for Nursing (Open RN); Chapter 4 Aseptic Technique. Available from: https://www.ncbi.nlm.nih.gov/books/NBK596727/ stated in part, "In addition to using standard precautions and transmission-based precautions, aseptic technique (also called medical asepsis) is the purposeful reduction of pathogens to prevent the transfer of microorganisms from one person or object to another during a medical procedure ... When performed properly, aseptic technique prevents contamination and transfer of pathogens to the patient from caregiver hands, surfaces, and equipment during routine care or procedures. The word "aseptic" literally means an absence of disease-causing microbes and pathogens. In the clinical setting, aseptic technique refers to the purposeful prevention of microbe contamination from one person or object to another. These potentially infectious, microscopic organisms can be present in the environment, on an instrument, in liquids, on skin surfaces, or within a wound."