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Based on observation and interview, the facility failed to store food and ice under sanitary conditions.

Findings include:

1. Observation of the facility's kitchen freezer #5 on 8/21/12 at 9:10 A.M. found: 1 plastic bag with a frozen white substance without a label or date, 1 plastic bag of oyster sauce with date of 4/17 (no year), and 2 plastic bags of streusel that expired 1/2012. Interview with the kitchen's cook validated that the items were expired. The cook stated she labeled and dated the food items in the kitchen, but did not write the year as the facility used up the food items before the expiration date. The cook said the kitchen staff "know" when the items expire.

Interview was conducted with Food Service Manager (FSM) on 8/24/12 at 8:45 A.M. The FSM identified the frozen food item found in the freezer was without label or date and was half a can of coconut milk. FSM stated that while there was no written policy for labeling and indicating expiration dates on food items, the practice was to check once a week. The FSM said the items mentioned were missed.

2. Observation on the afternoon of 8/21/12 of the ice machine located in the kitchenette found a black substance on the inside left wall and back of the machine. The back portion was where the ice dropped into the bin. There was also a brownish substance on the pipe on the right hand side of the machine. The scooper for the ice was found uncovered and lay directly on the outside top of the machine.

On the morning of 8/22/12, the Administrator validated the presence of the brown and black substances in the ice maker and stated that the parts of the machine needed to be cleaned. Interview with the Maintenance Supervisor on 8/22/12 at 8:30 A.M. revealed the facility did not have a regular maintenance cleaning schedule of the ice machine but that the cleaning was to start on 8/22/12 and continue weekly. A log was developed to be kept on the side of the machine to ensure the ice maker was cleaned. The service log contained columns with date, time, initials, comments, machine name, model #, serial # and location. The supervisor also stated a contracted company came twice a year to maintain the machine.

Based on staff interview and policy review, the facility failed to have policy and procedures for infection control in radiology services.

Finding includes:

Interview was conducted with the Radiology Technician (RT) on 8/23/12 regarding an overview of the department and its services. During the interview, surveyor queried about infection control practices as the department services patients from the community as well as long term care residents. The RT stated that sometimes the staff alerts him if the patient is infectious and that gloves were available in case he needed to utilize precautions.

Review of the Radiology Policy and Procedure Manual revealed there were no guidelines for infection control practices and guidelines. The RT acknowledged that there was no written policy for infection control in that department.

During an interview with the Infection Control (IC) nurse on 8/22/12 at 1:55 P.M., she verified there was no policy and procedure for infection control practices/guidelines in the radiology department.