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Based on the manner and degree of deficiencies cited, the hospital failed to comply with the Condition of Participation of Physical environment. The facility failed maintain the food and dietary department, and its facilities and supplies, to ensure the safety of the patient when providing food and nutrition services.
The facility failed to meet the following standards under the Condition of Patient Rights:
TAG A 701 - MAINTENANCE OF PHYSICAL PLANT
The facility failed to ensure that the condition of the physical plant and overall hospital environment was maintained in such a manner that the safety and well-being of patients were assured. The facility failed to maintain a clean environment in the food and dietary department for the safe preparation and storage of food.
TAG A 724 - FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE
The facility failed to maintain the facilities, supplies and equipment in the food and dietary department to ensure an acceptable level of safety and quality.

Based on tour/observation, staff interviews and review of hospital documents, the facility failed to maintain a clean environment in the food and dietary department for the safe preparation and storage of food. The failure placed all patients, visitors and staff who consumed food prepared/served from the host hospital food and dietary department at risk of food borne illness.
Findings:
1. Food Services Department Tours/Observations with Concurrent Staff Interviews:
On 7/9/12 at approximately 2:30 p.m., the food and dietary department was toured with the Food Services Director, the Plant Operations Director and the Chief Executive Officer (CEO) of the tenant hospital. Observations and concurrent interviews with the staff were conducted throughout the tour.
Findings:
a. The floor in the kitchen was covered with red square tile with white grout. In the area by the large unit of cooking surfaces and grills, the tile looked very dirty with a black greasy substance that was dripping down the vertical square tiles and grout on the platform on which the cooking equipment was mounted. The black greasy substance also extended onto the tiled floor in front of the cooking/grilling equipment. The grouted areas appeared especially dirty from the black greasy substance. It appeared to be long-term accumulation of grease and dirt from cooking at the unit. When asked about the frequency of cleaning and techniques to clean the tile and the grouted areas, the director of plant operations for the host hospital stated that the floors were cleaned daily and that they were doing deep cleaning in some areas of the department, as needed. When asked if the grout was sealed to prevent the dirt and grease from absorbing into the grout, s/he stated that the grout was already sealed, by its very nature, and did not require an extra sealant.
b. During a tour of the alcove area where the mechanical dishwasher was located, there was standing water on the floor in the doorway. The staff member rinsing dishes to place in the machine and the food services manager both stated that the standing water was due to a "floor drain back up."
c. The findings were also confirmed by the the Chief Executive Officer (CEO) of the tenant hospital, who was present on the tour.
2. Dietary Policy/Procedure Review:
Review on 7/10/12 of the Dietary policy/procedure manual revealed that the manual contained no guidelines for general cleaning and safe use of cleaning equipment and chemicals in areas where food was stored, prepared and served.

Based on tour/observation, staff interviews and review of hospital documents, the facility failed to maintain the facilities, supplies and equipment in the food and dietary department to ensure an acceptable level of safety and quality. The failure placed all patients, visitors and staff who consumed food prepared/served from the host hospital food and dietary department at risk of food borne illness.
Findings:
1. Dietary Policy/Procedure Review:
a. On 7/10/12, the dietary policy/procedure entitled " Infection Control - Proper Food Handling " was reviewed and revealed the following, in part:
" PURPOSE: Preventing food borne illness.
POLICY: The following procedures are vital to infection control and must be considered in addition to those covered in previous sections.
M. All food items that are prepped in-house must be labeled and dated with production date. Items must be discarded 3 days after production date.
N. Packaged food items with expiration dates do not need to be dated and will be disposed of on the expiration date located on the packaging. "

b. On 7/10/12, the dietary policy/procedure entitled " Dietary - Scope of Care" was reviewed and revealed the following, in part:
"PURPOSE:
To maintain fresh, quality product.
POLICY:
In order to ensure quality of spices and herbs, spices are to be kept no longer than one year after opening and three years after unopened.
PROCEDURE:
All spice containers will be dated and taken from storeroom with month and year. Any spice still on shelf after one year will be discarded."

c. On 7/10/12, the dietary policy/procedure entitled " Dietary - Scope of Care" was reviewed and revealed the following, in part:
"PROCEDURE:
Food Services
A. High quality food service is provided to patients. This includes patient meal service and catering for special functions sponsored by the hospital. All foods are prepared using sanitation, preparation and service techniques which will maintain quality, retain nutrients, flavor and enhance aesthetic appeal. Patient meals are prepared to coincide with the diet prescription ordered by the physician and patient food preferences.
Performance Assurance Program
A. The Food Services Department will participate in the hospital-wide Performance Improvement Program to ensure high quality food services are provided to the patients. Monitors to identify problems will be ongoing and will reflect the plan of care of the hospital.
B. Identify opportunities for improving food safety to enhance patient health and promote consistent food safety services."

d. Review on 7/10/12 of the Dietary policy/procedure manual revealed that the manual contained no guidelines for labeling prepared foods once opened, inspecting previously opened food containers for evidence of bacterial growth or contamination, or for discarding prepared foods once they were opened. The manual also contained no guidelines for inspection of produce or how long it should be kept after the delivery date. The manual contained no guidelines for securing opened container of bulk frozen foods to prevent airborne contamination. The manual contained no guidelines for use of the 3-compartment sink used for manual dishwashing to ensure correct water temperature controls, chemical concentrations and immersion times and regular testing of the concentrations with a test strip. Finally, the manual contained no guidelines for proper cleaning of equipment such as the electric meat slicer, the floor-mounted electric mixer, the refrigerators and freezers and for general cleaning and safe use of cleaning equipment and chemicals in areas where food was stored, prepared and served.

2. Food Services Department Tours/Observations with Concurrent Staff Interviews:
On 7/9/12 at approximately 2:30 p.m., the food and dietary department Food Services Director, the Plant Operations Director and the Chief Executive Officer (CEO) of the tenant hospital. Observations and concurrent interviews with the staff were conducted throughout the tour.
Observations in the Food Services Department:
a. Loaves of white bread were found sitting on counters, under-counter shelving and on bread racks along with buns. None of the loaves or packaging of bread products contained any dates, such as production dates, open dates, last use dates, or discard dates. The food service director stated that bread was not usually kept longer than a week.
b. A repairman was observed working on an ice-making unit in the open kitchen kitchen area near serving and food preparation stations. The unit was open and there appeared to be large collection on the inner walls of the unit with what looked like a combination of light brown slime mold and mineral deposits. When asked about the conditions in the icemaker, the director of plant operations stated that the machine was not used for patients. S/he stated it was used for the cafeteria and catering and never for patient use. The dirty cloth tool bag, used by the repairman, was later found sitting on shelving containing non-perishable food in cans, bottles and boxes on shelving. The dirty/greasy-appearing tool bag was sitting on cases of canned foods. The bag was removed and returned to the repairman when the surveyor asked about the bag.
c. Tour of a walk-in refrigerator with primarily produce contained a previously-opened, plastic-lined, cardboard box that contained some kind of greens. When asked to identify the contents, the food services director stated s/he thought it was rosemary. On further inspection, s/he determined that it was mint. There was a large patch of what appeared to be grayish-white mold in the box on the top layer of mint. The patch appeared to be an oval area of mold growth. The patch was approximately 3 inches by 4 inches. The director confirmed that the mint appeared to have mold growth. There was no date on the box stating when it should be discarded. The director stated that the only date they used on any of the produce was the delivery date sticker on the boxes and bags from the supplier. S/he was unable to describe a standard for how long produce was kept after delivery. In the same refrigerator was found a container of grapefruit that was labeled "use by 2/12/12." In addition, a cardboard box with a supplier delivery sticker of 4/18/12 contained approximately 2 dozen limes. Approximately 4-5 of the limes were completely withered and brown and there were brown patches on at least 4-5 more of the limes. The director removed the limes from the cooler when s/he was shown the condition of the limes in the box. S/he said they should be discarded. One shelf contained a large bag of cabbage heads with a date of 6/13/12. Two heads of cabbage were sitting on the shelf in front of the bag. They both appeared to having black moldy patches on the outer leaves. The director was unable to say how long those cabbages had been there. S/he stated that they usually have that condition of mold on the outer leaves of the head, but they remove the outer leaves and then use the cabbage. A cardboard box was found on lower shelf containing more heads of cabbage. The cabbage heads appeared much more moldy with a bluish-back mold on the leaves and covering the site where the cabbage head was harvested from the stalk. The manager again stated that the cabbage was frequently moldy, but the mold was removed with removal of the outer leaves, and the cabbage would be use. The cooler also contained a previously-opened, plastic-lined cardboard box containing dried cranberries. The box was folded closed, but there was no evidence of an attempt to seal the plastic liner to protect the dried cranberries from airborne contamination or leakage of liquids from other boxes in the cooler.
d. Tour of a walk-in freezer located near the shelves of canned goods revealed that breaded frozen cod was in a previously-opened, plastic-lined cardboard box. There was no attempt to seal the plastic bag to protect the contents from cross-contamination. There was no evidence of labeling of contents of the freezer for date opened or a discard date. On the floor outside of the freezer was a large plastic jug of bottled water that appeared to be partially full, sitting on the floor in front of the shelving that contained cases of canned goods. When asked about the bottle on the floor, the director stated that the bottle was serving as a doorstop for the freezer. There was no label on the bottle stating that it was being used for that purpose and was not to be used as drinking water or for cooking. The plant operations manager stated that the bottle was one that had been taken from their supply of surplus emergency drinking water that was stored in another area. Both directors assured the surveyor that the staff all knew that the bottle was used as a doorstop and the contents would never be used for cooking or drinking water.
e. On some of shelving that held shelf-stable stocks of food and canned goods, a previously-opened, large cardboard milk carton-shaped box, containing dehydrated sliced potatoes, was found open to the air, without the opening of the box secured, creating the potential for airborne or vermin contamination of the contents.
f. In one of the refrigerated pantries was found a covered Styrofoam cup containing a white liquid. The cup and lid had no label or marking indicating the contents, date opened, or a discard date. The food service manager asked another staff member and determined that it was "lactate," a milk substitute. S/he acknowledged that the cup should have been properly labeled and dated. In another refrigerated pantry, two large covered disposable drinking cups were found to contain a liquid which was believed to be iced tea. The cups and lids were not labeled identifying the contents or a preparation or discard date. The director of food services again confirmed that the cups should have been labeled and dated.
g. A large, previously-opened plastic container of yogurt, was found in one of the refrigerated pantries with a date on the lid of 6/8/12. The director was asked how long the opened container would be kept. S/he stated that they use a standard of discarding "perishable" foods after 3 days, but for something in a manufacturer's container, they go by the manufacturer's expiration date, whether the containers was previously opened or never opened. When asked it they adjusted the discard date to factor in the possibility of an earlier expiration dated due to cross-contamination/bacterial growth once a sealed container was opened, the director stated that they did not factor that in, but merely relied on manufacturer's expiration dates.
h. A shelf of spices and herbs was observed with some plastic lids sitting open and no evidence of dating of the bottles when opened.
i. Another refrigerated pantry contained a very large mixing bowl that appeared to contain tuna fish salad. The bowl had been covered with plastic cling wrap, but the wrap was loose and not sealing the bowl from airborne or drip contamination of the contents. The director of plant operations stated that that pantry's contents were not for patient food. S/he stated that the tuna was for the cafeteria line. In the other side of the same pantry were found patient snack servings of what appeared to be canned fruit with pre-printed stickers with a date and patient names on them. The food services director did confirm these were for patients. The pre-printed stickers had the date of 7/6/12, which would have been longer than the discard date for "perishable" food, according to the director of food services. S/he stated that the labels were actually printed the day before the food was placed in the single serving containers, so that even though it appeared that they were 4 days old, they were only 3 days old. There were lots of pre-printed labels on the counter that had not been used. It appeared that it would be very difficulty to accurately rely on those labels to know when a food had actually been prepared, versus when the label was printed, to ensure an accurate and safe discard date for "perishable" foods. The containers had no other dating with the black markers that appeared on some of the labeled foods. The pantry also contained half of a purple onion wrapped in cling wrap, with no dates. A very large institutional size glass jar of olives, with approximately two inches of contents in the bottom of the jar, contained no open or discard date. Again, the director of food services stated that they relied on the manufacturer's expiration date for a discard date.
j. Another refrigerated cart/tower with racks for holding trays of foods contained foods that the director stated were for use that day. There were trays of white bread sandwiches wrapped in cling wrap and Styrofoam covered containers with the contents appearing to be canned fruit, flavored gelatin and pudding. There were also salads covered in cling wrap. No contents of that refrigerated cart were labeled with contents or date of preparation or expiration date. The food services director stated that the food was not labeled unless it was not used the day it was prepared.
k. Another refrigerated cart/tower with racks for holding trays of food was observed near one of the cooking stations. The upper trays contained condiments and jars of gravy/sauce bases. No jars were dated with open or expiration date, other than the manufacturer's expiration date. A jar of vegetable base with the lid unscrewed and ajar on top of the container had no dating of any kind, including no manufacturer's expiration date. Approximately 3/4 of the way down the cart was a tray of raw meat patties covered with cling wrap and dated with the day's date in black marker. Stored below the raw meat on lower racks were other non-meat foods including a square metal contain with contents identified by a staff member as cooked rice, which was covered in cling wrap. There was no date on the container of rice. On the bottom of the cart under the lowest rack, there was a large dark red stain on the white interior surface of the cart. The stain appeared to be dried blood from dripping meat products.
l. A large open closet contained shelving with food preparation and storage equipment, as well as what appeared to be punch/serving bowls. They appeared dusty and were open to the air. The director of plant operations stated that area was for storage for the catering that was also done by the food service department. In the other side of the open closet the cleaning supplies and cleaning products and a janitorial floor shower drain were observed. The janitorial supplies were separated from the catering supplies by a partial wall that ran perpendicular to the open doorway and partially separated the two parts of the closet. The janitorial area appeared dirty on the walls and floor. A rack of hanging cleaning equipment included a broom. The directors of food services and plant operations were asked if they were aware that the state licensure requirements prohibited dry dusting and sweeping in any area of the hospital, to prevent airborne contamination. They both acknowledged that they were unaware of that regulation.
m. Observation of the meat slicer sitting on a countertop revealed that the slicing surfaces appeared clean on visual inspection, but the lower part of the machine below the sliding cradle appeared to be contaminated with old grease and dirt and the same was found at the control area of the slicer.
n. Observation of a floor-mounted electric mixer revealed that the bowl and mixing blades were not present, but the mixer support frame, which held the bowl in position was heavily covered with a white dried substance that appeared to be a long-term accumulation of flour and batters from the machine. When asked how often the mixer was cleaned, the director of food services stated that it was cleaned every day and that the staff had just done some mixing with the machine. The crusted accumulation of what appeared to be flour and batters was observed to be evident up and down the length of the mixer support stand and did not appear to have been recently cleaned.
o. Observation of the 3 sinks for manual washing and rinsing of pots and large items revealed that the two outer sinks had hoses running to the automatic sanitizer dispenser above both sinks. The middle sink did not have a hose to supply any chemicals to that sink. All three sinks were empty. There was no evidence of any marks on the sink or measuring system to insure the correct amount of water was used with the automatic dispensers. The director of plant operations stated that the chemicals were automatically dispensed with the push of a button and the systems was checked regularly to make sure the dispensers function properly. S/he stated that records of the checks were available for review to the surveyor. The surveyor asked it the staff did checks of the water solutions on a daily basis to ensure that they had the correct/effective dilutions's and temperatures. S/he stated the staff did them every day, but they kept no record of the testing. There were two previously-opened tubes of test-strips sitting on a lower shelf below the sinks. The test strips had no expiration or efficacy dates visible on the tubes. The tubes appeared covered in dust.
p. Reference Tag A 701 for additional tour/observation finding related to dirty areas on the floor by the cooking /grilling areas and the standing water in the dishwasher alcove related to a "floor drain back-up."
q. The findings were also confirmed by the the Chief Executive Officer (CEO) of the tenant hospital, who was present on the tour.