HospitalInspections.org

Based on record reviews, facility policy reviews, and staff interviews, the facility failed to: notify the physician upon the initiation of restraints (See A168.); renew restraint orders as stated in the facility's policy (See A173.); and describe the patient's behaviors and interventions attempted prior to initiation of restraints (See A185 and A186.)

Based on clinical record reviews, policy review, and staff interviews, the facility failed to notify the attending physician immediately when restraints were applied to five (#s 30, 31, 39, 40, and 47) of 10 sampled patients. The facility failed to ensure that the current facility restraint policy included the required time interval for physician notification when restraints were applied to patients. Findings include:

1. On 5/24/10 at 2:00 p.m., the surveyor reviewed the facility's policy labeled "Restraint/Seclusion Guidelines." The surveyor noted the following statements documented under item E. "If Initiation of restraint/Seclusion is necessary, consider the following:...3. A Registered Nurse notifies a physician, physician assistant, or nurse practitioner for an order as soon as possible. The order includes the reason for the restraint. 4. A written order, based on an examination of the patient by a physician or designated licensed practitioner, is entered into the patient's medical record within 24 hours of the initiation of restraint."

2. On 5/27/10 at 8:35 a.m., the surveyor asked an intensive care (IC) staff nurse to explain the restraint application procedure. The IC staff nurse stated that if the patient was an open heart surgical patient, the physician would send a restraint order with the patient's chart. The patient would remain in the restraint until they woke up and were extubated. If the patient was on the ventilator, or had a lot of lines and started pulling at the equipment and was not easily redirected, the IC staff nurse would place the patient in restraints, and then get a restraint order within 24 hours of the placement of the restraints.

3. Patient #30, a 71 year-old female, was admitted to the Intensive Care Unit (ICU) on 5/13/10. The patient was admitted with issues with breathing and pleural effusion.

During the clinical record review, the surveyor noted that on 5/13/10 at 1:00 p.m., the facility initiated bilateral wrist restraints. At 3:49 p.m., the restraints were discontinued. The clinical record did not contain an order for the use of restraints, or documentation of physician notification of the initiation of the restraints.

According to entries in the electronic medical record (EMR), the ICU staff initiated soft wrist restraints on 5/14/10 at 2:00 p.m. The physician signed the restraint order on 5/24/10 at 9:30 a.m., 10 days after the restraint was initiated. The surveyor noted an ICU Restraint Orders form dated 5/14/10, that contained no documentation of the time when the order was written. The order was for soft restraints for bilateral wrists and legs. The patient was confused or disoriented and unable to follow instructions consistently after staff had attempted other alternatives. The patient persisted in trying to disconnect medical equipment and/or pulling at the lines and tubes. The staff tried verbal instruction as an alternative to the restraints. The facility educated the patient and family on the use of the bilateral wrist and leg restraints. The medical record lacked documentation of the physician being notified of the initial placement of the restraints.

According to entries in the EMR, the ICU staff initiated soft wrist restraints on 5/20/10 at 6:00 a.m.

The surveyor noted an ICU Restraint Orders form dated 5/21/10 at 12:00 a.m.

The physician signed the order on 5/21/10 at 11:45 a.m. The medical record lacked documentation of the physician being notified when the restraints were initiated.

4. Patient #31, a 54 year-old male, was admitted to the facility on 5/19/10. The patient was admitted with hyponatremia and supraventricular tachycardia with bigeminy.

On 5/23/10 at 8:00 p.m., the ICU staff initiated bilateral wrist restraints.

On 5/24/10 at 8:30 a.m., the physician signed the restraint order. The medical record lacked documentation of the physician being notified when the restraints were initiated.

5. Patient #39, a 49 year-old male, was admitted to the facility on 5/3/10. The patient was admitted with complications from end stage liver disease.

On 5/3/10 at 10:00 a.m., an ICU staff nurse initiated and documented the initiation of the soft limb restraints. The clinical record lacked a physician order for the use of restraints and documentation of when the physician was notified that the restraints had been initiated.

6. Patient #40, a 94 year-old female, was admitted to the facility on 4/19/10. The patient was admitted with abdominal pain.

On 4/19/10 at 9:29 a.m., an ICU staff nurse entered a nursing order in the EMR for wrist restraints.

On 4/19/10 at 10:00 a.m., the ICU staff initiated bilateral wrist restraints.

On 4/19/10 at 11:30 a.m., the physician signed the restraint order. The clinical record lacked documentation of the physician being notified when the restraints were initiated.

7. Patient #47, a 78 year-old female, was admitted to the facility on 4/8/10. The patient was admitted with respiratory distress.

On 4/8/10 at 9:00 p.m., the ICU staff initiated the ICU Restraint Order form.

On 4/8/10 at 10:00 p.m., the ICU nursing staff applied bilateral wrist restraints.

On 4/9/10 at 7:00 a.m., the physician signed the restraint order. The clinical record lacked documentation that the physician had been notified when the restraints were initiated.

On 4/26/10 at 6:00 p.m., the ICU nursing staff initiated soft limb restraints. The clinical record lacked an order for the restraints and documentation of physician notification of the restraint placement.

Based on record reviews, facility policy review, and staff interview, the facility failed to renew restraint orders as stated in the facility's policy for four (#s 30, 34, 39 and 47) of 10 patients reviewed. Findings include:

1. On 5/24/10 at 2:00 p.m., the surveyor reviewed the facility's policy Restraint/Seclusion Guidelines. The surveyor noted the following statements documented under E. "If Initiation of restraint/Seclusion is necessary, consider the following:...5. Continued use of restraint beyond the first 24 hours requires a physician or designated licensed practitioner to examine the patient and renew the order if restraint continues to be justified."

2. Patient #30, a 71 year-old female, was admitted to the Intensive Care Unit (ICU) on 5/13/10. The patient was admitted with issues with breathing and a pleural effusion.

During the medical record review on 5/25/10 at 7:30 a.m., the following information was noted:

On 5/14/10 no time noted, an ICU Restraint Order form was filled out. The clinical record lacked documentation of a new ICU Restraint Order for 5/15/10 and 5/16/10. The nursing staff continued to document in the clinical record the use of soft limb restraints until 5/16/10 at 10:00 a.m., when the restraints were discontinued.

On 5/21/10 at 12:00 a.m., an ICU Restraint Order form was filled out. The physician signed the order on 5/21/10 at 11:45 a.m. The next ICU Restraint Order form was signed by the physician on 5/22/10 at 2:45 p.m. The physician's order for the restraint on 5/22/10 was 3 hours late. The ICU staff documented in the clinical record during this time the use of the soft limb restraints.

On 5/25/10 at 8:15 a.m., the ICU manger was interviewed, she did not know why the restraint was not ordered on 5/15 and 5/16/10.

3. Patient #34, a 75 year-old male, was admitted to the facility on 3/10/10. The patient was admitted with altered level of consciousness.

On 3/12/10 at 12:40 a.m., the physician wrote an order for soft wrist restraints.

On 3/13/10 at 3:00 a.m., the ICU staff initiated soft limb restraints.

On 3/13/10 at 4:27 a.m., the ICU staff started charting on the soft limb restraints.

On 3/14/10 at 4:30 p.m., the physician wrote an order to discontinue restraints.

The ICU staff documented in the clinical record the use of the restraints until 3/14/10 at 3:38 p.m. The clinical record lacked documentation of a physician's order to continue the use of the restraints on 3/14/10.

4. Patient #39, a 49 year-old male, was admitted to the facility on 5/3/10. The patient was admitted with complications from end stage liver disease.

On 5/3/10 at 10:00 a.m., the ICU staff documented the initiation of soft limb restraints.

On 5/5/10 at 11:00 a.m., the physician signed the ICU Restraint Order for 5/4/10.

On 5/3, 5/6, 5/9, 5/10, 5/13, and 5/14/10, the clinical record lacked a physician's order for soft limb restraints. The ICU nursing staff documented on these days that the patient was in soft limb restraints.

For six of twelve days, the patient's clinical record lacked a 24-hour renewal for the use of the soft limb restraints.

5. Patient #47, a 78 year-old female, was admitted to the facility on 4/8/10. The patient was admitted with respiratory distress.

On 4/8/10 at 9:00 p.m., the ICU nursing staff documented the initiation of soft limb restraints.

On 4/11/10 at 8:00 a.m., the physician signed the ICU Restraint Order.

On 4/12/10 at 4:20 p.m., the physician signed the ICU Restraint Order. The ICU nursing staff continued to document patient #47 was in restraints from 8:00 a.m. to 4:20 p.m., on 4/12/10. The patient was in restraints for over 8 hours before the physician reordered the soft limb restraints.

The surveyor noted an ICU Restraint Orders form dated 4/13/10, with no time. The physician signed the restraint order on 4/16/10 at 12:41 p.m., 3 days after the order was written.

Based on clinical record review, the facility failed to document or describe the patient's behaviors requiring, or less restrictive interventions attempted prior to initiation of, restraints for one (#47) of 10 patient charts reviewed. Findings include:

1. Patient #47, a 78 year-old female, was admitted to the facility on 4/8/10. The patient was admitted with respiratory distress.

According to the clinical record, the Intensive Care Unit (ICU) nursing staff initiated the ICU Restraint Order form at 9:00 p.m., on 4/8/10.

On 4/8/10 at 10:00 p.m., the ICU nursing staff initiated charting for the bilateral wrist restraints. The ICU staff nurse documented on the initial assessment on 4/8/10 at 10:00 p.m., that the patient was calm, with sedation or anesthesia confusion. The patient was "interfering with medical devices/tubes/dressings which may cause severe harm if the treatment was interrupted." The ICU staff nurse continued to document the above information on the two-hour restraint assessment on 4/9/10 at 12:00 a.m., and 2:00 a.m.

The documentation lacked a description of patient #47's behaviors and the less restrictive interventions that were attempted prior to the initiation of the soft limb restraints.

Based on record review, the facility failed to document the alternatives to, or the less restrictive interventions attempted prior to, the initiation of restraints for three (#s 31, 39, and 47) of 10 patient charts reviewed. Findings include:

1. 4. Patient #31, a 54 year-old male, was admitted to the facility on 5/19/10. The patient was admitted with hyponatremia and supraventricular tachycardia with bigeminy.

On 5/23/10 at 8:00 p.m., the Intensive Care Unit (ICU) nursing staff documented the initiation of the soft limb restraints for patient #34. The charting in the Electronic Medical Record (EMR) for 5/23/10 at 8:00 p.m., and 10:00 p.m., and on 5/24/10 at 12:00 a.m., 2:00 a.m., 4:33 a.m., and 6:32 a.m., did not include alternatives or less restrictive interventions attempted, before the restraints were initiated. The physician's order was signed on 5/24/10 at 8:30 a.m.

2. Patient #39, a 49 year-old male, was admitted to the facility on 5/3/10. The patient was admitted with complications from end stage liver disease.

On 5/3/10 at 10:00 a.m., the ICU nursing staff documented the initiation of soft limb restraints for patient #39. The EMR entries for 5/3/10 at 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m., and 6:00 p.m., did not include alternatives or less restrictive interventions attempted, before the restraints were initiated. The clinical record lacked a physician's order for the initiation of the restraints.

3. Patient #47, a 78 year-old female, was admitted to the facility on 4/8/10. The patient was admitted with respiratory distress.

On 4/8/10 at 10:00 p.m., the ICU nursing staff documented the initiation of the soft limb restraints for patient #47. The EMR entries for 4/8/10 at 10:00 p.m., and 4/9/10 at 12:00 a.m., 2:00 a.m., 4:00 a.m., and 6:00 a.m., did not include alternatives or less restrictive interventions attempted before the restraints were initiated. The physician's order was signed on 4/9/10 at 7:00 a.m.

Based on record reviews, the facility failed to ensure that all clinical record entries were completed for 17 (#s 6, 9, 10, 11, 12, 13, 30, 31, 34, 35, 36, 37, 39, 41, 42, 45, and 47) of 55 patient clinical records reviewed. Findings include:

1. The facility's ICU (Intensive Care Unit) Orders form contained the following areas to be completed: type of intervention ordered, reason for the intervention, alternatives to intervention attempted, and intervention explained to.

2. Patient # 30 - One ICU Restraint Order signed by the physician on 5/18/10, lacked documentation of the indication for the reason for the intervention, alternatives to the intervention attempted, or who received an explanation of the intervention.
-One ICU Restraint Order signed by the physician on 5/22/10, lacked documentation of the type of intervention ordered, reason for the intervention, alternatives to the intervention attempted, or who received an explanation of the intervention.
-Two ICU Restraint Orders signed by the physician on 5/23 and 5/24/10, lacked documentation of the alternatives to the intervention attempted.

3. Patient #31 - One ICU Restraint Order dated 5/23/10, lacked documentation of the alternatives to the intervention attempted.
-One ICU Restraint Order, signed by the physician on 5/22/10 at 2:45 p.m., lacked documentation of the type of intervention ordered, reason for intervention, or alternatives to the intervention attempted.

4. Patient #34 - one pastoral progress note dated 3/11/10, was not timed as to when the entry was made.
-One physical therapy progress note dated 3/13/10, was not timed as to when the entry was made.
-Two physician progress notes dated 3/15 and 3/16/10, were not timed as to when the entry was made.

5. Patient #39 - six physician progress notes between the dates of 5/3 and 5/4/10, were not timed as to when the entry was made.
-Two ICU Restraint Orders signed by the doctor on 5/11 and 5/12/10, lacked documentation of the type of intervention ordered, reason for the intervention, alternatives to the intervention attempted, or who received an explanation of the intervention.
-Two ICU Restraint Orders signed by the doctor on 5/7 and 5/8/10, lacked documentation of reason for the intervention, alternatives to the intervention attempted, or who received an explanation of the intervention.
-Two ICU Restraint Orders signed by the doctor on 5/5/10, lacked documentation of the alternatives to the intervention attempted or who received an explanation of the intervention.

6. Patient #47 - three physician progress notes dated 4/9, 4/10, and 4/11/10, were not timed as to when the entry was made.
-Six ICU Restraint Orders signed by the doctor on 4/8, 4/9, 4/10, 4/11, 4/12, and 4/28/10, lacked documentation of the reason for the intervention, alternatives to the intervention attempted, or who received an explanation of the intervention.
-One ICU Restraint Order signed by the doctor on 4/19/10, lacked documentation of the type of intervention ordered, reason for the intervention, alternatives to the intervention attempted, or who received an explanation of the intervention.
-One ICU Restraint Order signed by the physician on 4/27/10, lacked documentation of the reason for the intervention or who received an explanation of the intervention.


19464


7. Patient #6 - two physician progress notes dated 5/20 and 5/24/10, were not timed as to when the entries were made.

8. Patient #9 - one physician progress note dated 5/23/10, was not timed as to when the entry was made.

9. Patient #10 - eight physician progress notes dated 4/17, 4/22, 4/24, 4/25, 5/2, 5/9, 5/10, and 5/16/10, were not timed as to when the entries were made.

10. Patient #11 - five physician progress notes dated 5/18, 5/19, 5/20, 5/22, and 5/24/10, were not timed as to when the entries were made.

11. Patient #12 - eight physician progress notes dated 5/12, 5/15, 5/16, 5/17, 5/18 times 2, 5/19, and 5/20/10, were not timed as to when the entries were made.

12. Patient #13 - two physician progress notes dated 5/24/10, were not timed as to when the entries were made.

13. Patient #35 - Discharge instructions were not signed, timed, or dated by facility staff or patient/family.

14. Patient #36 - two progress notes dated 3/5 and 3/8/10, were not timed as to when the entries were made.

15. Patient #37 - twenty-four physician progress notes dated 1/18, 1/19, 1/19, 1/19, 1/19, 1/19, 1/19, 1/19, 1/20, 1/20, 1/20, 1/20, 1/20, 1/20, 1/21, 1/21, 1/22, 1/23, 1/26, 1/27, 1/29, 1/29, 1/30, and 1/31/10, were not timed as to when the entries were made.


20342


16. Patient #45 - one Progress Record dated 5/20/10, was not timed as to when the entry was made.


26492


17. Patient #42-consents for treatment dated 4/19/10 and 4/6/10, were not timed as to when the entries were made.

18. Patient #41- discharge instructions dated 5/25/10, was not signed, dated or timed by the provider.

Based on observations, staff interview and record review, the facility failed to:
- prepare food in a clean environment,
- assure that the plate warmer was cleaned regularly,
- assure a wall in the walk-in-cooler was attached,
- assure that water was not accumulating under the grill,
- assure to clean non-food contact surfaces of equipment,
- maintain required sanitizer level,
- properly wash hands after touching soiled surfaces in the kitchen,
- properly store kitchen equipment, utensils, and food items,
- properly date open food items being used,
- discard expired food items, and
- discard open, undated, unsealed food items in the freezers, coolers, and prep tables. (See A0619.)

Based on staff interviews, policy reviews, and observations, the facility failed to ensure that safe practices for food handling and kitchen sanitation were followed. Findings include:

1. On 5/25/10 at 7:40 a.m., during the initial tour of the kitchen, the surveyor requested the dietary manager (DM) test the bucket containing the sanitizer solution for wiping the counter tops by the coffee dispensing area. The test strip did not register above 100 parts per million (ppm) of Quat Solution Oasis 146. The DM refilled the bucket with water and the pre-measured dispensed solution of Oasis 146. The solution now registered 400 ppm. The buckets of sanitizer solution by the vegetable preparation area, the stove and cook area, and the three-compartment sink were tested by the dietary manager. None of the solutions registered above 150 ppm of Quat Solution Oasis 1146. The kitchen assistant stated that the buckets were filled at 5:30 a.m.

The dietary manager stated the quat solution should test between 200 and 400 ppm. She stated the buckets were changed as needed, for example, when the water was soiled with grease. She stated she would call the manufacturer of the product to request the solution product sheet.

The May 2010 Sanitizer Solution Log - U.S. was requested and provided. The instructions on the sheet stated "The Sanitizer Log must be completed twice a day for sample testing... Required concentration for Oasis 146 must be set at 150-400 ppm for all dispensing equipment, use on stationary equipment, spray bottles, solutions for storing wiping cloths." The available documentation indicated that on 15 of 25 possible opportunities, the solution was not tested in the morning and on 20 of 25 possible opportunities, the solution was not tested in the afternoon.

On 5/26/10 at 4:00 p.m., the DM provided a Quat Solutions...Proper Temperatures for Testing and Usage dated March 2007. This form indicated the following: "Elevated water temperatures do not negatively impact quaternary products. As long as proper concentrations are maintained, proper efficacy will exist within the specifications set by the U.S. Public Health Service Food Code for sanitizing food contact surface. However, ppm testing with Quat test papers must be performed with the solution at room temperature [approximately 65 - 75 degrees F (Fahrenheit)]."

The buckets tested had been filled at 5:30 a.m., so they were within the room temperature range. When testing with the Quat test papers, the range should have been 150-400 ppm.

2. During the initial tour of the kitchen on 5/25/10 starting at 7:40 a.m., the surveyor made the following observations:

-a section of the meat cutter blade edge had meat residue;
-the salad bowls in the vegetable area were stored uncovered and in an upright position;
-the metal shelving containing spices, next to the vegetable area, was greasy to touch. The DM stated she was not sure if this rack was on the cleaning schedule;
-there was food debris hanging from the mixing component of the vertical floor mixer;
-the four-tiered pot and pan rack had visible dust accumulation and was sticky to the touch; and
-the freezer contained pans of salsa chicken dated 5/7, chicken noodle soup dated 5/10, and a pan of chili dated 5/23. These pans were not sealed, the plastic wrap or tin foil covering the pans was pulled back. The DM stated that when the pans were placed in the freezer, they were not yet cooled, and the wrap was pulled back to prevent moisture from building up under the wrap.

3. The following handwashing/gloving observations were made on 5/25/10:
-8:30 a.m., in the Simply to Go area, a kitchen worker was making sandwiches. With gloved hands, she placed meat and cheese on buns. She then opened the refrigerator door to retrieve additional items. She threw away the glove she used to open the refrigerator door, and without washing her hands, she put on a clean glove. The DM was asked about the handwashing/changing glove policy. She stated that whenever gloves were changed, the kitchen worker was to wash hands prior to putting on a clean glove.
-9:30 a.m., a kitchen helper was observed taking trays of chicken from the oven and placing the chicken in smaller pans with tongs. He used a gloved finger to help position the chicken in the smaller pan. He took the large pan to the sink and using a hose, rinsed the pan off. He placed vegetables and gravy over the chicken, covered the pans, and placed them in a warmer. He then retrieved another large pan of chicken from the oven. He did not wash his hands or change his gloves after using the hose to rinse the soiled pan.
-9:45 a.m., a kitchen helper was observed washing her hands. She had to remove the lid to the large garbage container to place the wet paper towels she used to wipe her hands and contaminated her hands.

The DM provided the HACCP (Hazardous Analysis Critical Control Point)/Food Safety Program revised 8/2009. The policy indicated, "Hands must be washed frequently and correctly...after handling raw meat, poultry, seafood and produce, before working with ready-to-eat foods, between handling different types of food, after handling dirty equipment and after handling trash and other contaminated objects."


26492


4. On 5/25/10 at 7:30 a.m., the following expired, unsealed, opened and undated food items were observed in the freezers, coolers and prep tables, with the kitchen manager:

The prep table contained:
-Reduce Calorie Mayonnaise with an expiration date of 3/18/2010;
-Creamy Caesar salad dressing with an expiration date of 5/21/10;
-5 pound (lb) of cottage cheese with no open date;
-Tortillas opened and undated;
-Pepper jack cheese expired 5/19/10;
-Cheddar cheese expired 5/24/10;
-Container of lettuce with no date;
-Container of cantaloupe with no date; and
-Container of tomatoes with no date.

The freezers contained:
-an uncovered ice cream shake with a metal spoon inserted;
-an open 5 gallon container of vanilla ice cream with no open date;
-an open 5 gallon container of chocolate ice cream with no open date;
-an open 5 gallon container of strawberry ice cream with no open date;
-an unsealed exposed bag of chicken tenders with no open date;
-two unsealed exposed bags of chicken legs with no open dates;
-an unsealed exposed bag of mixed vegetables with no open date;
-an unsealed exposed bag of fries with no open date;
-an unsealed exposed bag of sausages with no open date;
-an unsealed exposed bag of onion rings with no open date; and
-an unsealed exposed bag of corn dogs with no open date.

The coolers contained:
-20 ready-to-serve cheesecake slices with no dates;
-a container of prunes with a fork in the container, with no open date;
-a container of salsa with no open date or expiration date;
-a bag of open whipped cream with no open date;
-an open case of Mozzarella cheese with the expiration date of 4/10/10;
-an open case of String cheese with the expiration date of 12/22/09;
-a 5 lb (pound) container open bag of Feta cheese that expired on 2/9/10;
-a 5 lb open bag of Gorgonzola cheese with no open date;
-a 5 lb open container of Ranch dressing that expired on 5/10/10;
-a 5 lb open container of Blue cheese dressing that expired on 4/20/10;
-a 5 lb open container of barbecue sauce that expired on 5/12/10;
-an open bag of shredded cheese with no open date;
-8 ready-to-serve tomato and basil sauce that expired on 5/21/10;
-a container of 6 hard boiled eggs without shells that were in greenish water that expired on 5/24/10; and
-a large container of mixed pancake batter, with a ladle in the batter, uncovered and undated.

The baking dry storage area contained no open dates for the following:
-an unsealed exposed 25 lb bag of corn meal with a best buy date of 2009;
-an unsealed exposed 50 lb bag of cake flour with a best buy date of 2009;
-an unsealed exposed 22 lb box of chocolate;
-an unsealed exposed 5 lb bag of cocoa powder;
-an open bottle of Kitchen Bouquet;
-an open case of chocolate mousse with a best buy date of 6/8/09;
-3 spray bottles of food lacquer that expired 3/11/09; and
-an unsealed exposed 20 lbs of dark chocolate with an expiration date of 11/18/09.

The dry storage area contained the following items being used without an open date:
-a container of Pancake and Waffle syrup;
-a container of Worcestershire sauce;
-Marsala Cooking Wine;
-Sesame Oil;
-Rice Vinegar;
-Light Corn Syrup;
-Molasses;
-Red Wine Vinegar;
-Kitchen Bouquet;
-Ranch dressing packet;
-Old Fashion Oats;
-Coconut with an expiration date of 1/12/10; and
-Hollandaise sauce.

At 8:00 a.m., the kitchen manager stated that the baking items had not been used since 2009. She stated all the items needed to have an open date and should have been thrown away a long time ago. She further stated all items were to be dated when opened and used by the 7th day. If the food items were not used by the 7th day, the items were to be thrown out.

5. On 5/25/10 at 7:30 a.m., during the initial tour with the kitchen manager, in the cooler there was part of the wall which was not attached properly.

6. On 5/25/10 at 8:00 a.m., during the initial tour with the kitchen manager of the baking area, the following were observed:
-The oven had an accumulation of debris hanging from the outside handles, and the outside of the ovens had grease build-up;
-There were greasy baking pans stored on the top of the oven;
-The wall behind the mixer and oven was covered with grease and food debris;
-Under the stand mixer, there was wet, brown debris build-up around the drain and on the floor;
-The pipes to and from the oven, mixer and floor drain were covered with reddish-brown grease debris;
-Under the prep table, the floor contained food items and the walls had a thick covering of brownish-red grease build-up;
-Under the prep table, there was a large hole in the tile wall;
-Two Hobart mixers were sitting uncovered with an accumulation of debris;
-There were mixing bowls stored upright with the mixing utensils in them. The bowls had a build-up of dust and debris; and
-The table that the two Hobart mixers were sitting on had grey grease build-up to the touch.

7. At 8:30 a.m., during the initial tour of the grill area with the kitchen manager, the following were observed:
-A puddle of brownish-orange water was noticed under the grill and stove;
-Behind the grill, the pipes were covered with thick black-brown debris;
-The steam pipes were cracked and dented; and
-The plate warmer had grease and food build-up on the inside where the plates were kept.