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Based on a direct observations and a review of the facility's files, there was no evidence that the Governing Body provided effective oversight to the entire facility and its operations.

Condition Level Non- Compliance was noted for the following:
Quality Assessment Performance Improvement,
Food and Dietetic Services,
Infection Control.

Findings include:

1. The Governing Body Committee Minutes from April 2012 present were reviewed on 7/8/13. The Governing Body Committee Minutes did not identify the following systemic issues:

The Governing Body did not ensure that the Food Service Department and the main kitchen were kept in a safe and sanitary condition. Refer to Tag #s A618 , A620, and A749.

The Governing Body did not ensure Physicians' Diet Orders met the recommended nutritional needs of all patients. Refer to Tag #s A628 and A629.

The Governing Body did not ensure that all contracted services were appropriately monitored by the Hospital. Refer to Tag # A263.

The Governing Body did not ensure that the entire facility was maintained in a safe and clean condition. Refer to Tag #s A747 and A749.

The Governing Body did not ensure that the entire facility was maintained in a fashion that would prevent the transmission of infections and food bourne illnesses. Refer to Tag #s A618, A620, A747 and A749.


The Governing Body did not ensure that the entire facility was maintained in a safe manner for its patients and the public. Cross refer to tag #s A701, A710 Life Safety from Fire, and Life Safety Survey findings referenced under Event ID # QORN21.

Based on interviews with the facility's staff and a review of the facility's files, there was no evidence that the Hospital maintained an effective Quality Assessment Performance Improvement Program for all of its Departments and the services rendered.

Findings include:

1. The Hospital Wide Quality Improvement Plan and its Committee Minutes for the past year was reviewed from 5/6/13 to 5/7/13. This included a review of all contracted services and agreements.

2. The Departmental and Hospital Wide Committee Minutes did not identify the following issues:

The environment of the kitchen was not maintained in a safe and sanitary condition to prevent the possibility of contamination and the transfer of infection.

The QAPI program did not monitor the main kitchen for sanitation, safe practice for food handling and food preparation.

The Quality Assessment Performance Improvement Program (QAPI) did not monitor the effectiveness of all contracted services.

The QAPI Program did not ensure that Physicians' prescribed diets met the therapeutic nutritional needs of all patients.

The QAPI program did not ensure that the entire facility was maintained in a safe and sanitary condition.

Refer to Tags cited below at A 273, A 618, A 620, A 628, A 629, A 631, A 701, and A 749. The findings noted above were verified by interview with facility staff throughout all dates of the survey and pertinent details are noted in each cross-referenced citation.

Based on interviews with staff and a review of the facility's files, there was no evidence that the QAPI Committee had a plan or indicators to monitor the performance of all contracted services, including those services rendered by the Food Service Department.

Findings include:

The facility's Hospital Wide Quality Improvement Plan and the Hospital Wide Quality Improvement Committee's Minutes from April 2012 to April of 2013 were reviewed on the following dates: 5/6/13 to 5/7/13. This included a review of the all of the facility's Departmental Committees Minutes for the above timeframe including the data that was reported up to the Hospital Wide Committee.

The facility's contract for the Food Service Department was reviewed on 5/9/13 at 11 a.m. A review of this contract revealed that the facility had an agreement with an outside vendor "Sodexo". This contracted agency had indicators for the Food Service Department, however, there was no documented evidence that the Hospital had its own plan or set of indicators to monitor the performance of the contracted service.

Staff #6, the Vice President of Human Resources and Axillary Services, was interviewed on 5/9/13 at 1:45 p.m. Staff #6 verified that the contracted agency Sodexo had its own indicators to monitor the performance of the Food Service Department. Staff#6 confirmed that the Hospital did not have its own indicators to monitor the Food Service Department. Staff#6 related that while some of the employees of the Food Service Department are contractors, this Department employs some Hospital based staff as well.

Staff#6 stated that the Hospital ' s Food Service Department's performance is based on employee and patient satisfaction surveys and routine audits. Staff #6 stated that she conducts regular rounds of the Food Service Department once a week. However, Staff #6 was unable to provide any audits that were conducted by the Hospital.
In summary based on the indicators developed by Sodexo, the company performed audits of the Food Service Department for the past year. These audits failed to identify the systemic issues noted in the kitchen during this survey.

Based on medical record reviews and staff interviews, it was determined the facility failed to ensure that the medical staff provided quality care consistent with prevailing standards of practice. This was found in one (1) of thirty two (32) medical records reviewed. Specific reference is made to MR #13.

Findings include:

The medical staff failed to address a patient's hypotension when the blood pressure dropped below the patient's normal range.

MR #13 was an eighty-two year old patient who presented to the facility on December 16, 2012 after he had fallen at home. The patient who resided alone in his home had a history of frequent falls and a previous medical history which included Hypertension, Parkinson's Disease, Dementia, Coronary Artery Disease, Hypercholesteremia, S/P cardiac stents and S/P Right Hip Replacement.

Initial vital signs taken showed the patient's temperature was 99 F, pulse 108, respirations 20, B/P 128/84 and the pulse oxymetry was 88% on room air. Work-up revealed the patient had Right Bundle Branch Block, Pneumonia and Dehydration.

The patient developed septic shock and acute hypoxic respiratory failure, was intubated on December 17, 2012 and admitted to the ICU. The patient also developed pleural effusion and a chest tube was placed.

On December 27, 2012, the patient was extubated, "his condition remained stable" and he was transferred to general medical floor. The patient's condition continued to improve, but on January 1, 2013 at 8:11 AM and 9:00 AM, the patient became hypotensive. The blood pressure was checked once on 1/1/13 at 8:11 AM and twice at 9:00 AM and was noted to be 86/45 on each occasion. The previous reading at 3:15 AM was recorded as 165/106.

A cardiologist saw the patient, according to documentation at 12:15 PM that day (1/1/13), and noted the low reading. There was no evidence that this finding was addressed. The patient was found at 3:00 PM with difficulty breathing and coughing up frothy pink drainage. The patient's color changed from red to cyanotic and a code was called. The patient was noted to have pulseless electrical activity and despite resuscitative measures expired at 3:12 PM.

The medical staff failed to re-evaluate and revise the patient's treatment plan until approximately 6 hours later.

This finding was confirmed during medical record reviews and staff interviews with the Medical Director, Staff #4, on May 9, 2013 at approximately 3:45 PM.

Based on medical record reviews, policy reviews and staff interviews, it was determined the facility failed to ensure that a patient's nursing care was evaluated. This was found in one (1) of thirty two (32) medical records reviewed, MR #13.


Findings include:

The nursing staff failed to monitor a patient's hypotension when the blood pressure dropped below the patient's normal range. MR # 13 was an eighty-two year old patient who presented to the facility on December 16, 2012 after he had fallen at home. The patient's previous medical history included Hypertension, Parkinson's Disease, Dementia, Coronary Artery Disease, Hypercholesteremia, S/P cardiac stents and S/P Right Hip Replacement. Initial vital signs showed the patient's temperature was 99 F, pulse 108, respirations 20, B/P 128/84 and the pulse oxymetry was 88% on room air.

The patient developed septic shock and acute hypoxic respiratory failure, was intubated on December 17, 2012 and admitted to the ICU. The patient also developed pleural effusion and a chest tube was placed.

On December 27, 2012, the patient was extubated, "his condition remained stable" and he was transferred to general medical floor. The patient's condition continued to improve but on January 1, 2013 at 8:11 AM and 9:00 AM, the patient became hypotensive. The blood pressure was checked once on 1/1/13 at 8:11 AM and twice at 9:00 AM and was noted to be 86/45 on each occasion. The previous reading at 3:15 AM was recorded as 165/106.

The patient was found at 3:00 PM with difficulty breathing and coughing up frothy pink drainage. The patient's color changed from red to cyanotic and a code was called at this point. The patient was noted to have pulseless electrical activity and despite resuscitative measures expired at 3:12 PM.

The nursing staff failed to re-evaluate the patient despite the low blood pressure for 6 hours when his condition markedly deteriorated.

This finding was confirmed during interviews with Staff #12 on May 9, 2013 at approximately 3:30 PM.

Based on observation, staff interview, review of policies, quality assurance and infection control documents, it was determined that the hospital food and dietetic services was not organized and directed in such a manner so as to ensure that the environment of the kitchen is maintained in a safe and sanitary condition in order to prevent the possibility of contamination and transfer of infection.
Findings include:
The Condition of Participation for Food and Dietetics Services is not met due to failure of the hospital's food and dietetic services in maintaining safe and sanitary conditions in the kitchen . Additionally, the Food Service Director responsible, did not implement effective oversight of the daily operation of the dietary services
Refer to Tag #s A0620 and A0749.

Based on observation, staff interview, and review of documents, it was determined the Director of Food and Nutrition did not provide adequate oversight for the daily management of dietary services. The Food Service Director failed to monitor all areas of the kitchen including sanitation, safety practices for food handling, and food preparation.
Findings include:
A tour of the hospital kitchen and cafeteria was conducted on 5/6/13 at approximately 10 AM. The surveyor was accompanied by the Vice President of Human Resources (who oversees Food Service), Food Service Director and Executive Chef. Examples of issues observed, include, but are not limited to, the following :
A- A review of the Pureed Freezer Temperature Logs noted pureed foods kept in the freezer, had the following temperatures: the freezer temperature for 5/3/13, was 25 F degrees in the AM, on 5/4/13 the temperature was 30F degrees in the AM and PM., and on 5/5 the temperature was 10 F degrees in the AM and 12 F degrees in the PM. On 5/6 the AM temperature was 20 F degrees. These freezer temperatures were all out of range, since a freezer temperature should be 0 F degrees and below. There was no evidence of any corrective action taken.
1- The Cafeteria refrigerator contained milk containers, packaged salad plates and sandwich plates. These foods were warm to touch. The milk temperature was taken and it was observed to be at 50 degrees. All food items on this rack were disposed of by the facility staff.
2- The above refrigerator had three shelves; each shelf had a rubber lining placed by kitchen personnel to prevent food from sliding. However, these rubber mats prevented the cold temperature to reach the food items on the shelves.
4- The Salad Bar Refrigerator in the Cafeteria was unplugged. This refrigerator was checked and it was found room temperature. This refrigerator contained bowls of cottage cheese, shredded yellow chesses, mozzarella balls and mushroom salad , cut broccoli and multiple large bottles of open salad dressing.
5 The staff were unable to state when these foods were placed in this unplugged refrigerator .Due to the inability to determine the safety of the food for purposes of consumption, the food items were discarded.
6- The tray line starter was observed to pick up the pellet plate before it was completely charged or hot. As a result , the Director of Food Service retrieved the pellet plate from the employee.
It should be noted that if the pellet plate is not completely charged, the hot foods served would not be maintained at the required temperature range.
B-The Food Service Director did not develop a feasible Emergency Preparedness Food Supply Manual designed for use by any personnel in the event of a disaster. The existing manual was lengthy and not designed for practical use during an emergency. Further, this Emergency Food Supply Manual was incomplete and did not contain the following essential information: a 3 day menu, a diagram where emergency food/water/paper supplies are stored, the emergency food supply count on inventory, the emergency supply count required per patient unit, and the water supply required by each patient care unit. In addition, there was no emergency food supply count for staff in the event of an emergency. Other required supplies, such as aprons, can openers, and flashlights, were not included in the emergency preparedness plan.
A tour of the facility on 5/6/13 revealed that there were no emergency supply of enteral feedings on hand.
C- There was no evidence that the Food Service Division of the Food and Nutrition Department had an ongoing quality assurance program to address matters pertaining to the Food Services Division.
During the tour, the Food` Service Director informed the surveyor that sanitation audits and food safety audits were done, but they were not included in a specific quality assurance program.
The Food Service Department had no specific indicators. Although the Department performed brief audits, there was no evidence that corrective action was taken when problems were identified. Example- Sanitation.(Cross-ref to Tag # ' s A0749 and A0618)
The findings as noted above were confirmed during interviews and inspection of the kitchen on 5/6/13 with the Food Service Director, the Executive Chef, and Vice President of Human Resources (who oversees Food Service).
.(Cross-ref to Tag # ' s A0749 and A0618)

Based on staff interview as well as review of master menus and nutrient analysis of menus, it was determined that that the Food and Nutrition Department did not ensure that physician prescribed diets met the therapeutic nutritional needs of patients.
Findings include:
A review of the nutrient analysis of the hospital menus was conducted on 5/7-5/9/13. The review of the nutrient analysis of the menus (one week cycle menu) was conducted with the Clinical Nutrition Manager. Listed below are the unacceptable findings identified in the nutrient analysis documentation:
1- The hospital' s Regular diets were calculated at 2000-2500 calories for all menus; however therapeutic diets were calculated at 1800 calories or less. Calories were not adjusted on therapeutic diet to meet recommended daily intake (RDA's/RDI ' s).
2- High Fiber diet should contain 28 grams of Fiber per day yet the average amount of Total Dietary Fiber provided on the menus for 5 days provided was approximately an average of 16.36 grams of fiber per day. Therefore, this diet did not meet the prescribed diet of High Fiber. In addition, this nutrient analysis was incomplete; it was missing the nutrient analysis for Saturdays and Sundays (this finding was based on review of a one week cycle menu).
3- The facility did not calculate nutrient analysis for daily diets for each type of diet. Low Fat diet, Low Protein diet, 2 grams Potassium diet , Low Residue and Low Cholesterol diets documented only 1 day of nutrient analysis, for Mondays only. One week cycle menus reviewed had no evidence of nutrient analysis for these diets for the remaining days of the week, i.e., Tuesday-Sunday. Therefore, prescribed diets cannot be validated in the absence of a nutrient analysis for these days.
4- The following diets, including High Protein diet , Kosher diet, Lactose free diet, Vegetarian diet, Gluten Free diet , and Dysphagia diet, had no nutrient analysis calculated. Therefore, the validity of these physician prescribed diets could not be verified. This finding represents that physician orders cannot be validated, due to lack of nutrient analysis for these physician prescribed diets.
Further it was noted the Vegetarian diet is not prescribed by its subtype.
5- The Renal diet did not have a protein restriction. This does not meet the standard of practice for renal diets as per the facility's diet manual.
6- There was no Age-Specific menu developed for pediatric patients, since pediatric patients are admitted to the hospital intermittently.
7- The Consistent Carbohydrate Diet was not implemented in accordance with the facility's diet manual. For example, the nutrient analysis for the Consistent Carbohydrate Diet was assessed by calories and not by grams of carbohydrate per day, as required by the hospital's diet manual.
In addition, the facility had only one of three consistent carbohydrate diets that had an available nutrient analysis; yet this nutrient analysis was inaccurately measured as 2500 calories. Consequently, due to the lack of nutrient analyses calculated for diets, the accuracy of the physicians' diet prescription orders cannot be validated.
The findings as noted above were confirmed during interview with the Clinical Nutrition Manager on 5/9/13.

Based on staff interview and review of documentation for dietary menu and physician diet prescriptions, it was determined that the prescribed physician diet orders were not being accurately transcribed on patients' menus.
Findings include:
1- Physicians' diet orders were abbreviated on menus and did not match the documented diet orders. Consequently diet orders do not correspond or match with the diet documented on patient menus. The menu must correspond and match the documented diet listed on patient menus.
Physician prescribed diets were not transcribed to menus as ordered. Menus require the identification of a physician prescribed diet. Physician prescribed diet was abbreviated and could not be understood on the menu as per physician orders. An example of this was noted for the diet "Consistent Carbohydrate Diet ", which was read as CCD1800 on the menu; Diets such as High Protein, High Calorie, and Low Protein did not specify the amount of the restriction on the menu. Without the amount of the diet restriction the prescribed diet is incomplete.
2- In addition, the amount of food to be provided on the tray base on diet was not listed on the menu. Example includes: "1-carrots, 1-chicken gravy " was noted instead of 4oz. or ½ cup of carrots or 1oz. chicken gravy. Food amounts noted on menus did not match the nutrient analysis of the diets. Therefore physician diet orders cannot be confirmed based on limited documentation provided on the menus.
The findings as noted above were confirmed during interview with the Clinical Nutrition manager on 5/11/13 and on all dates throughout the survey.

Based on observation, staff interview ,and review of diet formulary and patient menus, it was determined that the facility failed to ensure that an approved therapeutic diet manual is used as guidance for ordering and preparing pediatric patient diets.
Findings include:
On 5/7/13 at 11:00AM medical record reviews was conducted in the presence of the Director of Emergency and Critical Care Services. The surveyor asked the Director of Emergency and Critical Care if pediatric patients are admitted to the hospital from the Emergency Department. The response provided was pediatric patients are admitted to the hospital if necessary.
On 5/7/13 , the Clinical Nutrition Manager was asked to provide the nutrient analysis for pediatric diets and there was none available. The Clinical Nutrition Manager informed the surveyor that there was no age specific menu for pediatrics. Pediatric patients who are admitted or treated are provided with an Adult Regular Diet. The hospital is missing age specific menus, pediatric diet manuals, and nutrient analysis for age specific pediatric patients. The hospital does not utilize a " Pediatric Diet Manual " as a reference when providing age specific food amounts on pediatric trays. Consequently , the hospital is lacking a pediatric diet manual, age specific menus, and nutrient analysis for age specific pediatric menus.

Based on observation and staff interview, the facility did not maintain a hospital enivornment that ensured the safety and well being of the patients.

The findings include:

1) On the morning of 5/6/13, observation in the Emergency Department revealed that two electrical duplex outlets were partially out the wall/loose. Specifically, these were located near the ER Nursing Station and within Exam Room 9.
- Electrical duplex outlet was partially out of wall/loose near the ER Nursing Station.
- In Exam Room 9 (1834) of Hall 8 in the ER there was a duplex outlet that was partially out the wall/loose.

2) On the morning of 5/6/13, observation revealed that the ceiling tiles in the vicinity of Hall 8 of the Emergency Department had multiple damaged ceiling tiles, and the ceiling track near Room 1806 was dangling from the ceiling.

3) On the morning of 5/6/13, observation in the Fast-Track area of Emergency Department revealed that there was a countertop located near Bay L that had 2 holes cut in it. Further inspection of this couter revealed that one of these holes was being used to throw garbage in.

4) On the morning of 5/6/13, observation in the Fast-Track area of Emergency Department revealed that a Refrigerator/Freezer had an accumulation of ice in the freezer portion. This is a repeat deficiency.

5) On the afternoon of 5/9/13, observation at the Medical Center at Croton-On-Hudson extension clinic revealed that:
a) The bathroom/changing rooms did not have nurse call bells installed.
b) The floor in the corner of the Dark Room was damaged.

The above mentioned observations were all concurrently confirmed by staff #16.

Based on observations, record reviews and staff interviews, it was determined that the facility failed to meet the applicable provisions of the Life Safety Code, NFPA 101, 2000 edition.

The findings include:

During the survey of the facility from May 6-10, 2013, Life Safety Code deficiencies were noted in multiple areas of the Code requirements and were cited under the following Fire/Life Safety Code K-Tags:

K17
K25
K33
K39
K47
K62

Of note, the findings referenced above were verified by concurrent staff interview with staff #16 during the dates noted in corresponding K tags cited.

Based on direct observational, staff interviews and a review of the facility's documents, there was no documented evidence that the Hospital maintained a sanitary environment to prevent and control the spread of infections and other communicable diseases including food bourne illness.

Examples include: the staff in the Operating Room did not practice appropriate hand hygiene, the appropriate airflow/pressures were not maintained in the Central Supply Area, the Endoscopy Suite, and the Operating Room, staff were not knowledgeable with the recommended procedure for the cleaning of Endoscopes, in several instances there was inappropriate storage of clean and dirty equipment, the environment in the main kitchen was not maintained in a sanitary fashion, temperatures of the food tested in the kitchen and cafeteria, did not meet required levels.

See Tags A 701 & A 749.

Based on observations, documents reviews and staff interviews, it was determined the infection control officer was not effective in her role in in identifying conditions that would potentially cause contamination and the spread of infections and failed to ensure that services were provided in a clean and safe environment. Additionally, the Hospital Infection Control officer failed to ensure that there was an effective system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients

Finding 1:

Staff did not perform hand hygiene when their hands became contaminated in the operating room. This was noted for two circulating nurses, Staff #7 and #14. On May 7, 2013 at 11:00 AM in OR #6, Staff #14 was observed rolling 2 clean sheets on top of a garbage bin then placed them on a table. Staff #14 proceeded to discard pieces of garbage and in the process touched the garbage bin. Staff #14 then opened sterile packages that were to be used in the surgery without sanitizing her hands between these tasks.

On May 7, 2013 at 11:05 AM, Staff #7 was also noted in OR #6 picking up a piece of garbage from the floor. She then opened a storage cabinet, removed a package, opened the sterile content near the sterile field and touched an open but covered package of surgical instruments without sanitizing her hands. She then discarded some items into the bin and removed and tied the garbage bag for disposal. Staff #7 then placed a clean garbage on the bin while touching the entire rim of the bin to secure the bag in place. At this point Staff #7 sanitized her hands. This finding was witnessed by Staff #15 at the time of the observation.

Finding 2:

On 5/6/13 observation within the hospital revealed that various "clean" supplies were stored inappropriately. Specifically:
a) In the Emergency Department Nourishment Center (i.e. Room 1822) there was an unused gauze pad roll and wrapped plasticware was found on top of the ice machine.
b) In the 4th. Floor Medical/Surgical Suite Clean Utility Room there were miscellaneous supplies (gauze pads, shampoo bottle, etc.) on the floor.
c) In both of the 3rd. Floor Medical/Surgical Suite Medication Rooms there were miscellaneous supplies being stored too close/touching the edge of the handwash sinks (supply trays, safety lancets, etc.)

On the morning of 5/6/13 observation at the Emergency Department revealed that the Nursing Station cabinets and drawers were damaged. Specifically:
a) Medical tape was observed holding together a ER Nursing Station drawer;
b) An accumulation of Medical Tape was found on the cove base of the Nurses Station located near Room 9;
c) The shelving laminate of the ER Nursing Station was cracked in several locations;
d) In Restroom 1818 there was a garbage can in the room that prevented the door from fully opening, and there was medical tape that was keeping a cabinet door shut.

During the survey of the hospital there were items that were in contact with the red sharps containers. Specifically:
a) On the morning of 5/6/13 observation of the 3rd. Floor Medical/Surgical Medication Room there was a IT wire that ran over and rested on the red sharps container.
b) On the afternoon of 5/7/13 observation of the Labor and Delivery Suite revealed that in Rooms 201 and 202 the privacy curtains were in contact with the red sharps containers.

On the morning of 5/6/13 observation within the corridor on the Labor and Delivery floor revealed that there were bugs crawling inside the window frame .

During the survey the air balancing of the hospital was not maintained. Specifically:
a) On the morning of 5/7/13 observation revealed that the Central Sterile Supply various items were stored in a square"common" space located in between Operating Rooms 1 through 4. Since these are not stored in an individual room, positive air pressure can not be maintained.
b) On the morning of 5/8/13 observation revealed that the Central Sterile Supply Clean Sterile Room had negative air pressure, and was lacking a hand-wash sink.
c) On the morning of 5/9/13 observation revealed that the Endoscopy Suite's Dirty Utility Room did not have negative air pressure.
6) On the morning of 5/7/13 observation revealed that the scrub sink located outside OR#3 did not have any hot water.

On the morning of 5/7/13 observation of the Operating Rooms revealed that clean supplies, positioning equipment, and specific patient related sterile equipment was stored in a common corridor.

On the morning of 5/9/13 observation of the Endoscopy Suite revealed the following:
a) The Dirty Utility Room did not have any Air or Vacuum suction connections installed, did not have a hand-wash sink installed, and the door lacked a self closure device.
b) The "dirty" sink in the Dirty Utility Room had no measurements on or near it to indicate the exact measurement of detergent that is dispensed nor the exact measurement of water that should fill up the sink for proper disinfection of the endoscopes. Concurrent interview revealed that staff #18 did not know these specific measurements. She stated that she was trained to use 1 pump of the detergent each time the endoscopes in the sink are disinfected, and to fill the water to an unknown set level.
c) Interview with staff #18 revealed that the initial cleaning of the endoscopes was done in the Procedure Room because this is where the Air or Vacuum suction connections were located.

The above mentioned observations were all concurrently confirmed by the Vice President of Operations, staff #16, on 5/9/13.


27378


Finding 3:
A tour of the hospital kitchen was conducted on 5/6/13 at approximately 10 AM. The surveyor was accompanied by the Food Service Administrator, Food Service Director and Executive Chef. The following issues were observed.
A. Temperature
1- Review of Puree freezer temperature log noted on 5/3/13 a temperature of 25 degree in the AM, on 5/4/13 the temperature was 30 degree in the AM and PM., and on 5/5 the temperature was 10 degrees in the AM and 12 degrees in the PM. On 5/6 the AM temperature was 20 degrees. These freezer temperatures were all out of range since a freezer temperature should be 0 degree and below. There was no evidence of corrective action taken.
2- Cafeteria refrigerator containing milk, packaged salad plates and sandwich plates were warm to touch. Milk temperature was taken and observed to be at 50 degrees. All food items on this rack were disposed. The shelves in this refrigerator (3) had each a rubber lining placed by kitchen personnel to prevent food from sliding. This rubber mat prevented the cold temperature to reach the food items on the shelves.
3- Cafeteria salad bar refrigerator was unplugged and at room temperature yet contained bowls of cottage cheese, shredded yellow chesses, mozzarella balls and mushroom salad , cut broccoli and multiple large bottles of open salad dressing. All foods were discarded when staff was unable to inform the surveyor the time the food was placed in this warm refrigerator.
4- The tray line starter was observed to pick up the pellet plate before it was completely charged. The Director of Food Service retrieved the pellet plate from the employee. If the pellet plate is not completely charged the pellet plate temperature would fall below the temperature required to maintain foods hot in the entrée.
5- The rubber gasket on the bottom door of the food warmer had holes and was detached from the door.
B. Unsanitary Environment
1- The hand washing sink next to the eyewash sink had clogged water in it. The Director of Food Service and Executive Chef attempted to remove the dirty water in the sink but were unsuccessful. Kitchen employees were unable to wash their hand in this sink. The drain was not working. The Food Service Director reported that the malfunctioning drain to the Engineering Department, which was corrected by the end of the day on 5/6/13.
2- Large gray plastic bin on counter next to the dish washing machine was covered with grime, dust and food debris. Inside the bin was cooking utensils.
3- A black plastic rack containing 10 water glasses turned upside down, was found to be at the bottom rack of an open steel cabinet. Glasses were exposed to dust.
4- The start of the tray line was exposed to black and gray dust attached to the surface of the motor and blowing to the tray-line.
5- Plastic container which held a roll of aluminum foil was noted to be dirty with grime and dried food was stuck to the plastic container.
6- China was stored in an open metal rack exposed to dust.
7- Plastic wrapped was placed covering the surface of the counter next to the plastic utensil bin. This wrap prevents proper sanitation of the counter.
C. Cross Contamination
1- Windows and window sill in front of cold preparation area was dirty and full of dust.
2- A large red fire extinguisher was found to be very dusty. It was located above an uncovered buffalo chopper.
3- Three chopping boards were in very poor condition. All were full of grooves and were discolored.
4- Chopping boards were stored in a rack on top of a counter that was greasy and full of food debris.
5- Rack below cooking counter has a stack of clean and dirty white towels.
6- Large toaster has heavy grease grime stuck to the equipment.
7- Two small steam kettles had food/water residue stuck inside of them. The grime appeared to be rust. Surveyor was informed that one of the steam kettles was used for hot water and the other steam kettle is not in use. The steam kettles had water and rust beneath them and questionable residue inside of them.
8- Food items throughout the reach in and walk in refrigerators were not labeled with the food item or date. The items found were a brown bag of French fries, open meatball bag, bag of ground beef, bag of shredded cheese and a mislabeled jar of cookies. The cookie jar noted cookie dough.
9- Utensil bins at the start of the belt line had a plastic wrap in the bin. This plastic lining had holes and appeared worn. One of the bins had loose plastic folks who were upright hence an issue of infection control when handled by the food service worker. In addition, another bin lines with plastic wrap contained tape and writing paper inside the bin.
10- Pink tray containing clean plastic coffee mugs turned upside down had a unknown dark liquid scattered throughout the tray.
11- Convection oven had dry old grease grime throughout the oven.
12- Reach in refrigerator in front of the cook ' s area had loose beef patties that were uncovered and placed on top of other food bags.
13- Pipe that was cover with an aluminum color wrap had shredded dusty aluminum tinsels hanging over a metal rack containing pots and pans.
D. Other findings:
1- Snack bar refrigerator had 5-white meat sandwiches in white and whole wheat bread. All the wrapped sandwiches was not labeled or dated.
2- Reach-in freezer contained a box of peas. The plastic bag containing the peas was left open and peas exposed. A bag of carrot was left open and located at the bottom of the freezer.
3- A large bag of small onion was opened with no label or date. A block of corn was wrapped in saran wrap with no label or date.
4- Kitchen floor was dirty and full of food debris.
5- Ceiling tiles were dirty and stained with grease (yellow).
6- An Ice scoop was being stored beside a sink and a dusty window sill.
7- Two carts filled with blue plastic racks were blocking the hand washing sink located in front of the dish washer.
8- Multiple mops, sweepers, buckets, plastic containers of cleaning agents were scattered throughout a corner of the dish washing area.
9- Two bottom ovens that were not used by the cook as per the Food Service Director; were observed to be very dirty with dried black food crust stuck throughout both ovens despite the fact that they are not in use.
10- Convection ovens had dry grease throughout ovens.
11- Aluminum foil used to cover drip tray on oven was dirty and had not been changed.
12- Garbage cans were uncovered throughout the kitchen.
13- Small black fan in the cold prep area placed on a dusty window sill had excessive amount of black dust.
14- A dusty radio was next to the fan in the cold prep area.
15- In the cafeteria, reach-in refrigerator had packaged sliced cakes and sandwiches with no label stating the name of the food item. These food items only had a label that stated " Sunday " .
16- Pizza warmer in the cafeteria had a bulb inside of the warmer with no cover. This can result in a hand being burned.
17- A dirty ladder was stored between a reach-in refrigerator and wall.


27522


Temperature:
On the morning of 5/7/13 the following was found:
- A freezer was identified to have a temperature of 35F. Within this freezer was: 6 bags of chicken, 14 bags of french fries, and 1 bag of black bean burgers.
- Ambient temperature of Walk-In Refrigerator was 46F (greater the 40F as required). The following was checked:
Tuna Salad - 42F
- Ambient temperature of Snack Fridge is 46F. This refrigerator held 1 qt of milk, some slices of cheese cake, and dairy creamer containers in it.

On the afternoon of 5/8/13 the following was found:
- Another interview with staff # 8, revealed that french fries in the freezer were refrozen, while the black bean burgers and the chicken were tossed out approximately 20 minutes after the interview with staff #8 on 5/7/13.

On the morning of 5/10/13 the following was found:
- Ambient temperature of Walk-In Refrigerator was 46F. Also, the food items within the refrigerator were checked and found to have the following temperatures:
Vegetable Soup - 44F
Checked Activia Yogurt - 41F
Unsanitary Environment:

On the afternoon of 5/6/13 the following was found:
- " Clean " staff aprons and plastic cups/bowls/plates (all in opened packages) were being stored under an in-use countertop;
- A bag of Magical Briquette was stored under a kitchen sink;
- Miscellaneous cleaning supplies (mops, cleaning solutions, garbage cans, etc. being stored in the Dirty Dish receiving area;
- Dirty racks of various equipment up against the kitchen windows.

On the afternoon of 5/8/13 the following was found:
- a dirty knife was found under the freezer;
- A dusty large fan was located directly over/near various countertops in the corner of the kitchen.