HospitalInspections.org

Based on observation, review of facility documents and staff interview (EMP), it was determined the facility failed to ensure a sanitary environment in the Dietary Department.

Findings include:

Review on January 10, 2018, of the facility's "Director, Food & Nutrition" job description, no review date, revealed "... Job Requirements ... Complexity: Evaluates, directs and manages the function and structure of the Food & Nutrition Department. Ensure all regulatory standards are adhered to. Develops & oversees departmental goals and objectives. Job Impact: Initiate policies & procedures that are within established framework to assure facility meets all regulations. Implements & oversees policies & procedures that comply with all federal, state & local regulations. ... Essential Job functions ... 6. Monitor all required regulatory & quality control measures for compliance & proper documentation. ... 11. Coordinate departmental compliance with all federal, state & local health & sanitation regulations & requirements as evidenced by successful completion of surveys. ... 14. Plan / coordinate cleaning programs to assure regulatory compliance. ... 18. Perform department & unit walk-through to spot check activities to assure quality services are provided in an effective manner at all times. 19. Ensure all tasks are performed according to job flow; efficiently; safely & hygienically. ..."

Review on January 10, 2018, of the facility's "Executive Chef" job description, no review date, revealed "... Essential Job Functions ... 14. Organize, monitor & maintain department cleaning program to include al [sic] work areas & surfaces; floors, refrigeration/freezer units; storage areas; equipment & shelving. Delegate regularly; fairly & consistently to all staff. ..."

Review on January 10, 2018, of the facility's "Food & Nutrition Services Department New Employee Orientation Handbook" last updated August 2014, revealed "... Uniforms ... Hair - must be neat, clean and properly restrained in hairnet or hat. If you wear a hat and your hair does not totally fit under it, a hair net must also be worn. Jewelry - is limited to smooth wedding bands and professional type post earrings (nothing larger than the size of a pea). ..."

Review on January 10, 2018, of the facility's "Policy #500 Temperature Control of Patient Meals" last revised January 2014, revealed "Policy: To maintain food at proper temperatures during patient meal service. Purpose: To serve foods at proper temperature and maintain quality of food products. ... Procedure: A. Before the state of each meal period all equipment designed to maintain food at proper temperature is checked to be sure it is operational. B. Prior to the start of each meal period, temperatures are recorded and there is an evaluation of the temperature (as well as the taste and appearance) of food. ..."

Review on January 10, 2018, of the facility's "Policy #504 Food Handling Guidelines (HACCP)" last revised January 2014, revealed "Policy: Food is handled using a HACCP [Hazard Analysis and Critical Control Point - an internationally recognized system for reducing the risk of safety hazards in food] process in accordance with regulatory guidelines. Purpose: To have a delineated procedure for safe food handling techniques for employees handling food. ... Procedure: ... Cold Food Preparation 1. Potentially hazardous ingredients for foods that are in a form to be consumed without cooking such as salads, sandwiches, filled pastry products, cut leafy greens and produce, and reconstituted foods shall have been chilled to 41 degrees Fahrenheit (5 degrees C) or below prior to preparation. Products are chilled again after preparation to 41 degrees Fahrenheit (5 degrees C) or below. 2. Remove from refrigeration only quantities of food that are immediately needed for preparation and can be processed within 30 minutes. Return unused food (ingredients) and prepared food to refrigerator storage within the shortest time period possible to ensure that potentially hazardous food does not exceed 45 degrees Fahrenheit. ... Holding Temperatures (during preparation, service, and chilling) 1. Hold potentially hazardous foods at temperatures of 140 degrees Fahrenheit or greater or 41 degrees Fahrenheit or less, except during necessary periods of preparation, service and chilling. During preparation, services and chilling, foods should not be exposed to temperatures between 41 degrees Fahrenheit or 140 degrees Fahrenheit for more than two hours. Discard any potentially hazardous food that has been held between 140 degrees Fahrenheit or greater or 41 degrees Fahrenheit for over two hours. These guidelines do not address food quality but food safety. Quality should always be an issue when handling food. All times listed are accumulative times spent in the danger zone throughout the process. ..."

Review on January 10, 2018, of the facility's "Policy #514 Ventilation Hood Systems and Filters" last revised January 2014, revealed "Policy: Cleaning of hoods and filters. Purpose: For sanitation, safety and regulatory purposes. ... Procedure: 1. All Food and Nutrition Services Department exhaust hood filters are cleaned on a regular basis. Filter removed, cleaning & replacement is the responsibility of the Maintenance Department. 2. Food and Nutrition Services Department kitchen grease exhaust system is cleaned semi-annually by [name of cleaning company]. The semi-annual cleanings are in compliance with NFPA [National Fire Protection Association] 96 regulations. 3. The cleaning performed by [name of cleaning company] includes high pressure washing and chemically cleaning of all hoods, connecting ductwork, fans and filters. 4. Complete kitchen grease exhaust system cleaning is performed after department hours to prevent cross-contamination."

Review on January 10, 2018, of the facility's "Policy #520 Food and Equipment Sanitation Practices" last revised January 2014, revealed "Policy: All employees in the Food and Nutrition Services Department shall practice sanitation and safety measures. Purpose: To maintain a benchmark of sanitation and safety in a food services establishment. ... Procedure ... Health & Disease Control ... Cleanliness of Personnel ... D. ... Hairnets, caps and other effective hair restraints shall be used by employees engaged in food preparation and service of food when necessary, to keep hair from food and food contact surfaces. Hair must be totally contained in head cover at all times. ..."

Review on January 10, 2018, of the facility's "Policy #521 Department Cleaning Responsibilities" last revised January 2014, revealed "Policy: Definitive description of who will be responsible to clean specific areas, equipment or structures within the Food and Nutrition Services Department. Purpose: To document specific cleaning responsibilities. ... Procedure: ... 2. All areas / equipment in the Food & Nutrition Services Department are found on the cleaning schedule and are to be completed as scheduled. ... 5. If needed, due to department activity & need, equipment is to be cleaned sooner than specified on the cleaning schedule. ..."

1) Observation on January 10, 2018, of the facility's food delivery loading dock revealed a rolled-up entry door. There was dirt, dried leaves, dust and debris hanging from the bottom of the entry door.

Interview with EMP4 on January 10, 2018, at the time of the observation confirmed the facility's food delivery loading dock rolled-up entry door had dirt, dried leaves, dust and debris hanging from the bottom. EMP4 revealed food deliveries entered directly into the dietary area from the loading dock thru this rolled-up entry door.

2) Observation on January 10, 2018, of the walk-in freezer, refrigerator 1, refrigerator 2 and refrigerator 12 revealed an accumulation of dried food, dirt, dust and paper debris under the storage racks in the freezer and refrigerators.

Interview with EMP4 on January 10, 2018, at the time of the observations confirmed the walk-in freezer, refrigerator 1, refrigerator 2 and refrigerator 12 had an accumulation of dried food, dirt, dust and paper debris under the storage racks.

3) Observation on January 10, 2018, of refrigerator 11 revealed an accumulation of black/gray dust on the top and along the side of the inside door frame measuring approximately the size of a golf ball when gathered together.

Interview with EMP4 on January 10, 2018, at the time of the observation confirmed the accumulation of black/gray dust on the top and along the side of the inside door frame measuring approximately the size of a golf ball when gathered together.

4) Observation on January 10, 2018, of the ventilation hood over the hot food preparation area revealed seven ventilation / filter panels. These ventilation / filter panels had a thick coating of gray dust on the outside panels measuring approximately the size of two golf balls when gathered together.

Interview with EMP4 on January 10, 2018, at the time of the observation, confirmed the ventilation hood over the hot food preparation area revealed seven ventilation / filter panels had a thick coating of gray dust on the outside panels measuring approximately the size of two golf balls when gathered together.

5) Observation on January 10, 2018, of the pizza oven, toaster and waffle maker revealed an accumulation of dried food debris and gray dust measuring approximately a half-dollar in size when gathered together.

Interview with EMP4 on January 10, 2018, at the time of the observation confirmed the gray dust measuring approximately a half-dollar in size and the dried food debris on the pizza oven, toaster and waffle maker.

6) Observation on January 10, 2018, of the pot hanging rack over the food preparation areas number 6 and number 10 had an accumulation of gray dust on all the lateral and horizontal surfaces measuring approximately the size of a golf ball when gathered together. There was also an accumulation of gray dust on the utensil hooks that measured approximately the size of a golf ball when gathered together.

Interview with EMP4 on January 10, 2018, at the time of the observations confirmed the pot hanging rack over the food preparation areas number 6 and number 10 with an accumulation of gray dust on all the lateral and horizontal surfaces measuring approximately the size of a golf ball when gathered together and the accumulation of gray dust on the utensil hooks that measured approximately the size of a golf ball when gathered together.

7) Observation of EMP6, EMP7, EMP8, EMP9 and EMP12 on January 10, 2018, at approximately 11:00 AM revealed these employees working in the dietary department preparing patient trays and preparing food for patient consumption. The hair of EMP6, EMP7, EMP8, EMP9 and EMP12 was not completely restrained in their hairnets.

Interview with EMP4 on January 10, 2018, at approximately 11:00 AM confirmed EMP6, EMP7, EMP8, EMP9 and EMP12 were working in the dietary department preparing patient trays and preparing food for patient consumption without all hair restrained in their hairnets.

8) Observation of EMP4, EMP10 and EMP11 on January 10, 2018, at approximately 10:50 AM revealed these employees' facial hair was not restrained with a cover.

Interview with EMP4 on January 10, 2018, at the time of the observation confirmed EMP4, EMP10 and EMP11's facial hair was not covered while in the Dietary Department. Further interview revealed the facility does not have a policy addressing covering facial hair when working in the Dietary Department.

9) Observation of EMP12 on January 10, 2018, at 11:05 AM revealed this dietary employee working on the tray line preparing meal trays for distribution to patients. EMP12 was wearing large hoop earrings that rested on the collar of their shirt.

Interview with EMP4 on January 10, 2018, at the time of the observation confirmed EMP12 was working on the tray line preparing meal trays for distribution to patients, and this employee was wearing large hoop earrings that rested on the collar of their shirt. EMP4 confirmed these large hoop earrings were not appropriate for any dietary staff person to wear while working in the dietary department.

10) Review on January 10, 2018, of the "Tray Line/Taste/Temperature Record" form, no review or revision date, revealed a space to record the food portion size, the menu item, the utensil dietary staff use to serve the food item, temperature in Fahrenheit (including the temperature range, temperature of the food at the start and midway through serving, taste satisfactory or unsatisfactory, appearance satisfactory or unsatisfactory, the line check and productivity state and stop times.

Review on January 10, 2018, of the Tray Line/Taste/Temperature Records for November 2017 revealed:
Breakfast:
November 7, 2017 - French Toast, Cottage Cheese, Pureed Cottage Cheese and Banana
November 9, 2017 - Cottage Cheese and Yogurt
November 12, 2017 - Scrambled Egg Substitute, Yogurt Parfait and Cottage Cheese
November 17, 2017 - Scrambled Egg Substitute, Pureed Scrambled Eggs, Oatmeal, Pureed Cottage Cheese and Banana
November 27, 2017 - Scrambled Egg Substitute, O'Brien Potatoes, Pureed Turkey Sausage, French Toast, Pureed French Toast, Bacon Strips, Oatmeal, Cream of Wheat, Cottage Cheese

Lunch:
November 7, 2017 - Grilled chicken over Salad, Grilled Chicken Sandwich and Chicken Salad Sandwich
November 14, 2017 - Grilled chicken over Salad, Grilled Chicken Sandwich and Chicken Salad Sandwich
November 17, 2017 - Chicken Breast, Mashed Potatoes, Hamburger on Bun, Pureed Caramel Peach Crisp and Turkey Sandwich on White Bread
November 20, 2017 - Green Beans / Carrots, Peach Cobbler, Puree Peach Cobbler, Peach Slices, Cobb Salad, Turkey Sandwich on White Bread, Garden Salad, Lettuce and Tomato, Milk 2% and Skim and Turkey Salad
November 21, 2017 - Chilled Pears, Pureed Pears, Vanilla Pudding / Fresh Fruit Cup, Garden Salad, Grilled Chicken Caesar Wrap, Grilled Chicken over Salad, Grilled Chicken Salad, Chicken Salad Sandwich on White Bread and Milk 2% and Skim

Dinner:
November 18, 2017 - Apple Pie, Applesauce, Puree Apple Pie, Tuna Salad on Wheat, Tuna Salad Sandwich White Bread, Scoop of Tuna Salad, Garden Salad, Milk 2% and Skim
November 19, 2017 - SR Tomato Soup, Garden Salad, Fruit Salad, Banana Pudding with Topping, Banana, Chicken Salad Wrap, Chicken Salad Sandwich on White Bread, Milk 2% and Skim
November 25, 2017 - Pureed Apple Pie and Scoop of Tuna Salad
November 27, 2017 - Tropical Fruit Parfait, Ham and Turkey Sandwich on White, Turkey Sandwich on White, Grilled Cheese Sandwich, Garden Green Salad, Milk 2% and Skim

There was no documentation on the Tray Line/Taste/Temperature Records for the above dates that the temperatures of the foods were taken and recorded at the start or at the midpoint of service to ensure these foods were safely handled prior to serving to patients.

Review on January 10, 2018, of the Tray Line/Taste/Temperature Records for December 2017 revealed:
Breakfast:
December 3, 2017 - Yogurt Parfait, Cottage Cheese Peach Slices, Yogurt Parfait and Milk 2% and Skim
December 7, 2017 - Cottage Cheese, Yogurt and Milk 2% and Skim
December 22, 2017 - Buttermilk Pancakes, Scrambled Eggs, Pureed Scrambled Eggs, Scrambled Eggs with Ham, Cream of Wheat, Oatmeal and French Toast
December 29, 2017 - Cottage Cheese and Yogurt

Lunch:
December 1, 2017 - Chicken Breast, Mashed Potatoes, Hamburger on Bun, Carmel Peach Crisp, Pureed Caramel Peach Crisp, Turkey and Cheese Sandwich on White Bread, Turkey Sandwich on White Bread and Milk 2% and Skim
December 2, 2017 - Italian Hoagie, Roast Beef Sandwich on White Bread, Garden Salad and Milk 2% and Skim
December 3, 2017 - Fresh Fruit Cup, Puree Fruit cup, Peach and Pear Cup, Cottage Cheese and Fruit Plate, Cottage Cheese and Peach / Pear Plate and Milk 2% and Skim
December 4, 2017 - Cobb Salad, Turkey Sandwich on White Bread and Milk 2% and Skim
December 5, 2017 - Chilled Pears, Pureed Pears, Vanilla Pudding / Fresh Fruit Cup, Garden Salad, Grilled Chicken Caesar Wrap, Grilled Chicken over Salad, Grilled Chicken Salad, Chicken Salad Sandwich on White Bread and Milk 2% and Skim
December 13, 2017 - Chilled Pears, Pureed Pears, Vanilla Pudding / Fresh Fruit Cup, Garden Salad, Grilled Chicken Caesar Wrap, Grilled Chicken over Salad, Grilled Chicken Salad, Chicken Salad Sandwich on White Bread and Milk 2% and Skim
December 20, 2017 - Banana Cream Pie, Vanilla Pudding, Turkey Club Sandwich, turkey Sandwich on White Bread, Turkey Salad Sandwich on White Bread and Milk 2% and Skim
December 22, 2017 - Chilled Pears, Pureed Pears, Vanilla Pudding / Fresh Fruit Cup, Garden Salad, Grilled Chicken Caesar Wrap, Grilled Chicken over Salad, Grilled Chicken Salad, Chicken Salad Sandwich on White Bread and Milk 2% and Skim

Dinner:
December 1, 2017 - Vanilla Pudding, Turkey Sandwich on White Bread and Milk 2% and Skim
December 2, 2017 - Tomato Soup, Apple Pie, Tuna Salad on Wheat, Tuna Salad Sandwich White Bread, Scoop of Tuna Salad and Milk 2% and Skim
December 4, 2017 - Tropical Fruit Parfait, Ham and Turkey Sandwich on White, Turkey Sandwich on White, Grilled Cheese Sandwich, Garden Green Salad, Milk 2% and Skim
December 9, 2017 -Tuna Salad on Wheat, Tuna Salad Sandwich White Bread, Scoop of Tuna Salad and Milk 2% and Skim
December 13, 2017 - Carmel Peach Crisp, Peaches, Pureed Caramel Peach Crisp, Chef Salad, Turkey Chef Salad, Ham and Swiss on White Bread, Garden Salad, and Milk 2% and Skim

There was no documentation on the Tray Line/Taste/Temperature Records for the above dates that temperatures of the foods were taken and records at the start or at the midpoint of service to ensure these foods were safely handled prior to serving to patients.

Review on January 10, 2018, of the Tray Line/Taste/Temperature Records for January 2018 revealed:
Breakfast:
January 7, 2018 - Yogurt Parfait and Cottage Cheese
January 8, 2018 - Scrambled Egg Substitute, and Cottage Cheese

Lunch:
January 7, 2018 - Chicken Noodle Soup, Cream of Tomato Soup, Fresh Fruit Cup, Puree Fruit Cup, Peach and Pear Cup, Cottage Cheese and Fruit Plate, Cottage Cheese and Peach / Pear Plate and Milk 2%^ and Skim
January 9, 2018 - Grilled Chicken over Salad, Grilled Chicken Sandwich and Chicken Salad Sandwich on White Bread

There was no documentation on the Tray Line/Taste/Temperature Records for the above dates that temperatures of the foods were taken and records at the start or at the midpoint of service to ensure these foods were safely handled prior to serving to patients.

Interview with EMP4 on January 10, 2018, at approximately 2:15 PM confirmed there was no documentation on the Tray Line/Taste/Temperature Records for the above dates that temperatures of the foods were taken and records at the start or at the midpoint of service to ensure these foods were safely handled prior to serving to patients.

This Condition Level deficiency is the result of a Life Safety Code survey completed on January 17, 2018.