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Based on observation, interview and record review facility dietary staff failed to provide patient food service, using recognized food sanitation practices to prevent cross contamination of foods and possible food borne illness including the following:
-Failing to serve milk to patients at an appropriate temperature.
-Failing to effectively and consistently sanitize dishes, silverware and utensils used in patient food service.
-Failing to clean and maintain food storage equipment.
-Failing to store scoops so the handles of the scoops did not come in contact with bulk flour and bulk sugar.
-Failing to refrigerate opened food containers labeled by the manufacturer to "refrigerate after opening".
-Failing to store cases of disposable dishes and cups (used in patient food service) off the floor and away from soiled brooms, mops and mop buckets and caustic cleaning supplies.

The facility census was five.

Findings included:

1. Review of the U. S. Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2005 Food Code, Chapter 3-202.11 potentially hazardous foods (includes foods from an animal source) should be maintained at or below forty-one (41) degrees Fahrenheit.

Record review of the facility policy, titled "Food Temperatures" #8050-4.2 dated 10/10 showed direction for dietary staff to serve cold foods and beverages at or below forty-one (41) degrees Fahrenheit.

Observation on 11/29/11 at 12:12 PM on the patient unit showed dietary staff served a test tray with foods including a carton of two percent milk at fifty (50) degrees Fahrenheit.

During an interview on 11/29/11 at 12:12 PM Staff B, the interim Director of Dietary stated cold foods should be served at or below forty-one (41) degrees Fahrenheit.

2. Review of the U. S. Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2005 Food Code, Chapter 4-501.112 Mechanical Ware washing equipment, hot water sanitization temperatures should be at least one hundred eighty (180) degrees Fahrenheit.

Record review of the facility policy, titled "Dish Machine Temperatures" #8050-4.3 dated 10/10 showed the following direction for dietary staff:
-Check the dish washing machine temperatures at the beginning of the day and at noon
-Wash water temperatures and rinse water temperatures will be recorded.
-The rinse temperature will be at or above one hundred eighty (180) degrees Fahrenheit.
-If the temperatures do not meet the minimum, the Maintenance department will be notified immediately (for repair).

Review of the daily dish washing water temperatures dated 11/11 and reviewed on 11/28/11 at 12:50 PM showed the following:
-Staff failed to record temperatures for the beginning of the day on 11/27/11 and on 11/28/11.
-Rinse water temperatures at the beginning of the day were recorded as one hundred fifty two (152) degrees to one hundred seventy nine (179) degrees Fahrenheit for fifteen of twenty six days.
-Rinse water temperatures at noon were recorded at one hundred fifty six (156) degrees to one hundred seventy four (174) degrees Fahrenheit for twelve of twenty seven days.
-Lower than required rinse temperatures were recorded intermittently and for one extended period of twelve consecutive days.

During an interview on 11/28/11 at 12:50 PM Staff B confirmed the following:
-Maintenance staff has had to work on the dish washing machine.
-Dietary staff failed to record temperatures consistently.
-Dietary staff failed to have the Maintenance department repair dish washing machine so that the rinse temperatures were consistently high enough to sanitize dishes, silverware and utensils for the one extended period of twelve consecutive days.
-Some patients on isolation (with communicable diseases) were served meals on regular dishes and with regular silverware and washed in the dish washing machine with the other patient's dishes and silverware.

3. Review of the U. S. Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2005 Food Code, Chapter 4-601.11 (C) showed direction for staff to keep non food contact surfaces of equipment free of an accumulation of dust, dirt, food residue and other debris.

Record review of the facility policy, titled "Kitchen Sanitation" #8050-3.2 dated 10/10 showed direction for staff to clean each piece of equipment of all visible debris and sanitize with an appropriate sanitizing solution.

Observation on 11/28/11 at 12:25 PM in the facility kitchen showed staff stored multiple canned foods on a nine level can rack with dust and debris covered rails that were in direct contact with the rims of the cans.

During an interview on 11/28/11 at 12:25 PM Staff B confirmed the can rack was very dusty.

4. Review of the U. S. Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2005 Food Code, Chapter 3-304.12 "In-use utensils, between-use storage" showed direction for dietary staff to store dispensing utensils with their handles above the surface of the food.

Observation on 11/28/11 at 12:20 PM in the dietary dry food store room showed staff stored bulk containers of flour and sugar, each with a scoop lying on top of the food with the handles of the scoops in direct contact with the food.

5. Observation on 11/28/11 at 12:20 PM in the dietary dry food store room showed staff stored an opened one gallon container of Worcestershire sauce (contains fish called anchovies) unrefrigerated on a shelf. Further observation showed the manufacturer's label directed staff to "refrigerate after opening".

During an interview on 11/28/11 at 12:20 PM Staff B stated staff routinely stored the opened gallon of Worcestershire sauce unrefrigerated on the shelf.

Observation on 11/29/11 at 10:11 AM in the cook's area showed staff stored an opened one gallon container of soy sauce unrefrigerated on a shelf under the cook's prep table.
Further observation showed the manufacturer's label directed staff to "refrigerate after opening".

During an interview on 11/29/11 at 10:11 AM Staff B stated staff routinely stored the opened gallon of soy sauce unrefrigerated on the shelf.

6. Review of the U. S. Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2005 Food Code, Chapter 3-305.1 (2) and (3) showed direction for dietary staff to store foods and supplies used in food service where they were not exposed to splash, dust or other cross contamination and at least six inches above the floor.

Observation on 11/28/11 at 12:20 PM through 12:25 PM in the facility kitchen showed the following:
-Staff stored a cardboard case of disposable cups on the floor of the dry food storeroom
-Staff stored multiple cases of disposable cups, lids and other paper products used in food service on the floor of the mop closet in close proximity to a soiled mop bucket, brooms, mops and caustic cleaning products on shelving.

During an interview on 11/28/11 at 12:25 PM Staff B stated the disposable products were routinely stored on the floor of the store room and in the mop closet because there was no other place to store them.

Based on Missouri State Statute review, personnel record review and interview the facility failed to ensure individuals listed on the Employee Disqualification List (EDL, a listing of persons who had abused or neglected patients under their care) were not employed in the facility.

Record review of four (Staff D, G, H and B) of four staff showed the facility failed to effectively screen all staff by comparing the names of staff on hire and on a periodic basis after hire against the EDL.

The facility census was 5 patients.

Findings included:

1. Review of the Missouri State Statute RSMO 2003 Section 660.315 directed facilities licensed under Chapter 197 (hospitals) complete not only pre-employment EDL checks but also periodic checks of all existing staff against the quarterly updated EDL to ensure no current staff had been recently added to the EDL (The quarterly updated EDLs are available on the Missouri Department of Health and Senior Services web site).

2. Record review of Staff D's personnel file showed Staff D was hired on 10/11/06 as a consultant and the facility failed to check the EDL on hire and on a periodic basis to ensure Staff D had not been added since hire.

3. Record review of Staff G's personnel file showed Staff G was hired on 10/28/10 and the facility failed to check the EDL on hire and on a periodic basis to ensure Staff G had not been added since hire.

4. Record review of Staff H's personnel file showed Staff H was hired on 03/01/11 and the facility verified he/she was not on the EDL however failed to check on a periodic basis after hire to ensure Staff H had not been added since hire.

5. Record review of Staff B's personnel file showed Staff B was hired on 10/24/10 and the facility checked the EDL on 12/09/10 (over thirty days after hire) and failed to check on a periodic basis to ensure Staff B had not been added since hire.

6. During an interview on 11/29/11 Staff A, Chief Executive Officer (CEO) confirmed the facility Human Resources staff checked the EDL on hire, checked annually thereafter however did not have any proof of those annual checks.

Based on interview and record review the facility failed to develop and maintain an ongoing activities program for one current Swing Bed (Resident #11) and two discharged Swing Bed (Resident #7 and #9 ) residents that was based on a comprehensive assessment of leisure interests and abilities, care planned and directed by a qualified, trained Activities professional. The facility census was five (5) (one Swing Bed resident was admitted during the survey).

Findings included:

1. Record review of current Swing Bed Resident #11's physician's admission orders dated 11/28/11 showed the resident was admitted for physical therapy after a left hip fracture repair.

Record review on 11/29/11 at 12:20 PM of the resident's nursing notes showed staff had not completed an assessment of the patient's leisure interests or physical ability to participate in an activity program and failed to care plan for an activities program.

2. Record review of discharged Swing Bed Resident #7's physician's admission orders dated 09/07/11 showed the resident was admitted for physical therapy after a fractured femur repair.

Record review of the resident's Activity's Log showed staff recorded dated entries of the resident reading the Bible, newspapers or books however failed to document a comprehensive assessment of the resident's leisure activities, interests or abilities; and failed to care plan for activities.

3. Record review of discharged Swing Bed Resident #9's physician's admission orders dated 10/22/11 showed the resident was admitted for treatment after left hip replacement.

Record review of the resident's Activity's Log showed staff recorded dated entries from 10/30/11 through 11/05/11 of the resident reading books and watching DVDs
however failed to document a comprehensive assessment of the resident's leisure activities, interests and abilities and failed to care plan for activities.

4. During an interview on 11/29/11 at 11:05 AM Staff E, Chief Nursing Officer stated the following:
-The Activities Director position was organizationally under his/her supervision.
-The position had been vacant for a few months.
-An interested staff person had been selected during the survey to start as the Activities Director.
-The newly appointed Activities Director had not taken the State approved Activity Director's training program so, was not yet qualified.
-The facility planned to enroll the newly selected staff person in the State approved Activity Director's training program (to be completed on line).
-The current Activities program was done by nursing staff who offered each Swing Bed resident an activity twice during the day shift and once during the evening shift.
-Nursing staff make an informal verbal assessment of current leisure activity interests during those times when activities were offered to the resident.
-Nursing staff offered books, electronic games, community newspapers, magazines and videos from an activities cart.
-No formalized written initial assessment of leisure interests was documented.
-No assessment of the Swing Bed resident's abilities to participate in an activities program was documented.
-No assessment of the effectiveness of the offered activities was done each time a book, magazine, newspaper or video was documented.