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Based on observation, interview, and facility document review, the facility failed to maintain the kitchen walk-in freezer free of ice build-up.

This failure had the potential to result in contamination of food, decrease the quality of food, and pose a fall risk to staff.


Findings:


During an interview, on 9/23/24 at 3:15 pm, Dietary Services Manager (DSM) stated, that she did weekly kitchen inspections, and the Registered Dietitian (RD) did the monthly kitchen inspections, and these were documented on a sanitation checklist. The DSM's inspection checklists for the month of August, and September were requested. Also, the RD's checklists for the past four months were requested.

During an observation, in the kitchen on 9/25/24 at 2:37 pm, there was significant ice build-up inside and throughout the walk-in freezer. There was a large icicle over 12-inches in length and one inch thick hanging at the back of the freezer. There was also frost and ice on additional cases and containers of food. In addition, there was ice on the ceiling, the metal food storage racks, and there was thick ice covering the floor.

During a consecutive interview, on 9/25/24 at 2:40 pm, DSM stated, that the ice build-up was an ongoing issue. The DSM stated, that she documented the ice build-up consistently on her weekly Kitchen Sanitation Checklist. The DSM stated, that maintenance staff de-frosted the freezer, but the ice come back within a couple of weeks.

A review, of the "Kitchen Sanitation Checklist," completed and signed by DSM on 8/2/24, 8/8/24, 8/16/24, 9/6/24, 9/12/24, and 9/20/24, indicated that the freezer was not free from ice build-up.

During an interview, and document review, on 9/25/24 at 2:45 pm, the Facilities/Engineering Supervisor (FES) stated, that he was aware of the ice build-up in the freezer. FES stated, that there was a lot of moisture. FES stated, that the freezer was serviced and provided an invoice from an outside vendor dated 4/12/24, which he confirmed was the last time the freezer was serviced. When FES was asked about the continuous ice build-up despite the service on 4/12/24, FES stated, that he would not contact an outside vendor to service the freezer for ice build-up, only for out of range temperatures.

During an interview, on 9/26/24 at 9:30 am, the Director of Operations (DO, DSM Supervisor) stated, that she did not see the sanitation checklists from DSM.

During an interview, on 9/26/24 at 9:50 am, the Infection Preventionist (IP) stated, that she did not see the sanitation checklists from DSM.

According to the 2022 Federal Food Code, equipment is to be maintained in a proper state of repair.

Based on observation, interview, and record review, the facility failed to have complete patient care policies related to three out of six sampled patients (Patients 22, 23, and 25) when:

1. Patient 22 had an incentive spirometer (a device used to encourage taking deep breaths) without a physician's order, and the policy didn't indicate whether or not an order was required;

2. Patients 22, 23, and 25 had sedation assessments (an evaluation of the patient's level of alertness and breath rate) ordered by the Electronic Health Record (EHR) computer system with no documentation done by nursing. The facility had no policy about how to process these orders, or which sedation scales to use;

3. Hospital equipment was stored in patient room closets, and there was no policy about storing items in patient closets.

This failure had the potential to negatively impact the patients' health and well-being which could lead to negative clinical outcomes.


Findings:


1. A review, of Patient 22's EHR indicated, that they were admitted to the facility on 9/22/24. Patient 22's diagnoses included possible pneumonia (a lung infection), and history of a stroke. Patient 22 required supplemental oxygen, and had orders for nebulized (inhaled mist) medication treatments, but no incentive spirometer order.

During a concurrent interview, and observation, on 9/24/24 at 10:40 am, Respiratory Therapy Manager (RTM) confirmed, that Patient 22 had an incentive spirometer at their bedside. RTM stated, that an incentive spirometer given to a patient in the hospital required a physician's order.

A facility policy titled, "Incentive Spirometry (IS)," approved 7/25/19, was reviewed. The policy indicated that an IS was a component of bronchial hygiene (a set of techniques that helped clear mucus and secretions from the airways). IS was indicated for conditions that could have caused pulmonary atelectasis (when all or part of a lung collapsed). The policy did not indicate whether or not to obtain a physician's order for the device.

During an interview, on 9/25/24 at 3:48 pm, the Director of Nursing (DON) confirmed, that the IS policy did not specify whether or not a physician's order was required, and it was unclear whether or not the facility required a physician's order.

2. Further review, of Patient 22's EHR indicated a physician's order for hydrocodone-acetaminophen (brand name Norco, an opioid pain relieving medication that had the potential to cause drowsiness and slow the breathing rate) tablets every four hours as needed for pain. The EHR showed an order for, "Sedation Assessment High Risk Adult," to have been performed every one hour for 12-hours, then every two hours for 12-hours, then every four hours. The order read, "Assess for oversedation first 24-hours opioid administration, with new/changed opioid, addition of sedative or episode of respiratory depression, oversedation. When opioids are discontinued assess for oversedation as appropriate."

During a concurrent interview, and record review, on 9/23/24, at 3:35 pm, Registered Nurse (RN) 2 did not locate documentation about the sedation scales for Patient 22. RN 2 stated, that the orders for sedation assessments were automatically populated by the computer system.

During a concurrent interview, and record review, on 9/23/24 at 4 pm, RN 1 stated, that the order for Patient 22's sedation assessments should have been discontinued. RN 1 stated, that nursing usually notified the physician to ask if they would like to discontinue the sedation assessments. If nursing had documented and done the sedation assessments, they would have used the Richmond Agitation Sedation Scale (RASS), a 10-point scale used to determine a patient's level of agitation and sedation.

A review, of Patient 23's EHR indicated they were originally admitted to the facility on 4/10/24. Patient 23's diagnoses included dementia (a mental disorder that caused memory loss and confusion), transient ischemic attacks (TIA, a brief episode where blood supply to the brain was cut off), and atrial fibrillation (an irregular heart rhythm). Patient 23's physician's orders included Norco tablets every six hours as needed for pain. Patient 23 had sedation scales ordered by the EHR system.

During a concurrent interview, and record review, on 9/24/24 at 9:23 am, RN 2 did not locate any sedation assessments or RASS scores documented in Patient 23's EHR.

A review, of Patient 25's EHR indicated they were admitted to the facility on 3/30/24. Patient 25's diagnoses included right pelvic fracture, high blood pressure, and depression. Patient 25's physician's orders included, Norco tablets every six hours as needed for pain. Patient 25 had sedation assessments ordered by the EHR system on 3/31/24.

During a concurrent interview, and record review, on 9/25/24 at 3:51 pm, the DON did not locate any sedation assessments documented in Patient 25's EHR. DON stated, that the facility did not have a policy about sedation scales, or the sedation assessment orders.

3. During a concurrent observation, and interview, on 9/23/24 at 2 pm, in unoccupied patient Room 108, RN 2 confirmed there were items such as vinyl-covered cushions, a walker and a cane stored in the patient closet.

During a concurrent observation, and interview, on 9/23/24 at 2:01 pm, in unoccupied Room 106, the Housekeeper confirmed there were items stored in the patient closet. There was also dirt and sawdust on the floor of the closet.

During a concurrent interview, and record review, on 9/23/24 at 2:45 pm, the DON stated, that the facility did not have a policy about storage in patient closets.

Based on observation, interview, and record review, the hospital failed to develop and implement policies as evidence by:

1.The hospital did not adequately maintain and update the content lists for emergency crash carts, which could potentially lead to discrepancies between the actual contents of the carts and the documented lists. This lack of accurate information may pose risks during emergencies, as healthcare providers rely on these lists to quickly locate and administer necessary medications and supplies.

2.The hospital did not consistently follow best practices for medication labeling, as evidenced by the absence of dates on partially used insulin vials and the lack of dating for a medication removed from its overwrap. Proper labeling of medications, including the date of opening, is essential for ensuring medication safety, maintaining potency, and reducing the risk of contamination.

3.The hospital lacked a dedicated medication administration policy, which is essential for establishing standardized practices and ensuring consistent, safe medication administration across all departments. The absence of such a policy may contribute to variability in medication management practices, potentially compromising patient safety and quality of care.

4 & 5. The hospital did not adequately maintain medication supplies that have not become out of date. Removing outdated medications from patient care areas is essential for ensuring medication safety, maintaining potency, and reducing the risk of contamination.



Findings:


1. During an observation, on 9/24/24 on the medical-surgical floor, an adult crash cart was present. The content list indicated approval by PNT in 2018; however, the policy included an updated content list with additions not found on the 2018 list, such as flumazenil 1 miligram (mg) per 10 mililiters (mL), nitroglycerin 50 mg per D5W 250 mL, and epinephrine 4 mg per 250 mL.

During an observation, on 9/24/24 at 10:30 AM, in the surgery department, an emergency crash cart was present. However, the 2018 content list was found on the outside of the cart, while the updated 2021 content list was not visible. This raises concerns about the accuracy of the information readily available to healthcare providers during emergencies.

During an interview, on 9/24/24 with the Director of Pharmacy at 10 am, he acknowledged that the 2018 content list for the emergency crash cart was outdated and had been updated in 2021. He further explained that several changes had been made to the list, but the old content list had not been properly updated, resulting in some discrepancies.

During an observation, on 9/24/24 at 10:45 am, in the outpatient department, an emergency crash cart was present, but there was no content list on the outside of the cart. This poses a potential risk, as healthcare providers may not have immediate access to the information about the medications and supplies contained within the cart, which could lead to delays in treatment or errors during emergencies.

An accurate and up-to-date inventory of the emergency crash cart is critical to patient safety and effective emergency care. Inaccurate content lists can lead to missing essential medications or supplies, causing delays in treatment or adverse outcomes. Miscommunication may arise when healthcare providers expect certain items to be present but find outdated or incorrect supplies, increasing the risk of errors

2. During an observation, on 9/24/24 at 11 am, at the medical-surgical department's medication room, two findings were noted: partially used insulin that was not labeled with an expiration date, and an opened Advair medication that was stored outside of its overwrap without a dated label. These observations raise concerns about medication safety and the potential for decreased efficacy, or contamination.

A review, on 9/24/24 of the hospital policy titled, "Use of Multidose Vials," indicated that the expiration date for multidose vials should follow the manufacturer's recommended date listed on the vial. The policy further stated, that once a vial has been accessed, it should be disposed of after 28 days, assuming no visible contamination is present and standard precautions have been taken during handling.

During an interview, on 9/24/24 at 11 am, with the Director of Pharmacy, he mentioned that there was no specific policy on dating and labeling inhalers once they have been opened or removed from their overwrap. He acknowledged the importance of this practice and committed to adding these guidelines to the medication storage policy to ensure the safe use of medications within the facility.

During an interview, on 9/24/24 at 11 am, with the Director of Pharmacy, he acknowledged that opened insulin should be dated
upon opening and is typically good for 28-days. He also confirmed that Advair should be dated once opened and is generally stable for 45-days. The Director recognized that these labeling practices were not followed in the observed instances and committed to addressing the issue and ensuring proper medication labeling practices moving forward.

3. During an interview, on 9/24/24 at 9:20 am, with the Director of Pharmacy, he stated that there is no specific, titled policy for medication administration within the hospital. This absence of a formal, documented policy may pose challenges in ensuring consistent and standardized practices for medication management across the facility.

A review of the hospital's policies revealed that there was no specific policy dedicated to medication administration. The absence of a clear, standardized medication administration policy may hinder the hospital's ability to promote consistent practices and ensure patient safety in this critical aspect of care.




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4. On 9/25/24 at 3:30 pm, during a concurrent observation, and interview, of the "Mobile Clinic" (MC) with Medical Assistant 41 (MA41), an expired flu testing solution was found to have expired on 7/24 (July 2024). When asked MA41 stated another employee had, "told me it was still ok to use." MA41 later explained that the employee responsible for removing expired items, "doesn't work here any more." MA41 discarded the test solution from the patient care area.

Observations continued with MA41 in Exam Room 2 where an emergency supply box was found to have four expired containers of Diphenhydramine 25 mg per 10 cubic centimeters (weight and measure). MA41 stated, "I didn't know those were expired," and discarded them from the exam room. Physician Assistant-Certified 41 (PAC41) was also present and verified the items were out of date, and removed from the patient care area so they would not be used.



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5. During a concurrent observation, and interview, on 9/26/24 at 8:25 am, in the Rural Health Clinic procedure room, Telemedicine Coordinator (TMC) opened the emergency kit (a box filled with emergency supplies). The kit contained one Epipen (epinephrine-a medication used to treat life-threatening allergic reactions) 0.3 mg, and one EpiPen 0.15 mg. TMC confirmed the EpiPen 0.3 mg syringe had a printed expiration date of 6/2024, and the EpiPen 0.15 mg syringe had a printed expiration date of 7/24.

During a concurrent observation, and interview, on 9/26/24 at 8:35 am, TMC confirmed there were five multi-dose vials of Moderna brand COVID booster, lot number AS7642B, with no printed expiration date.

A review, of the Moderna vaccine Vial Expiration Checker, found online at: https://modernacovid19global.com/en-US/vial-lookup, indicated a field in which to enter the vaccine's lot number. When the lot number AS7642B, was entered in the search field, the page displayed the message, "Expiration date Oct. 13, 2023. Your vaccine has expired."

A facility policy titled, "Outdated Medications - Clinic," approved 5/31/23, was reviewed. The policy's purpose was to ensure outdated pharmaceuticals were not distributed to patients of the Rural Health Center. Outdated medications found during inspection were to be removed from stock and sequestered (isolated) and removed from the medication room site.

Based on interview, and facility document review, the facility failed to ensure menus for in-patient diets were in accordance with recognized dietary practices, as evidence by:

1. Lack of a comprehensive nutritional analysis of the patient menu for regular and therapeutic diets;
2. Lack of a basic nutritional analysis for the patient disaster menu; and
3. Lack of a disaster menu for Renal diets (a therapeutic diet designed for those with kidney failure).

The failure to ensure the nutritional needs of patients were met had the potential to result in worsening of patient prognosis which could lead to negative clinical outcomes.


Findings:


1. Review of the "Fall Menus Week: 1" signed by the Registered Dietician (RD), indicated available patient diets included Regular, Mechanical Soft (a texture modified diet that consists of foods that require minimal chewing), Puree (a texture modified diet that consists of smooth foods that do not require chewing), 2 Gram Sodium (a therapeutic diet that limits the amount of sodium to 2 grams per day), Low Fat/Low Cholesterol (a therapeutic diet that limits the amount of fat and cholesterol), Consistent Carbohydrate (CCHO; a therapeutic diet to help manage blood sugar with consistent levels of carbohydrate per meal).

During an interview, and concurrent document review, on 9/25/24 at 10:43 am, two documents titled "Menu Template Nutrition Summary," showed a 28-day average nutrient analysis for the Spring cycle CCHO and Regular menus. RD confirmed the only nutrient analysis available were for the CCHO and the Regular diet which showed nutrients for a 28-day average. RD confirmed the facility did not have a nutrient breakdown of the menu for each available patient diet and for less than a 28-day average (the average length of stay was 4.0 days). RD confirmed she was not able to determine whether the patient menus met the nutritional needs of the patients because there was not a nutrient analysis, as related to the Food and Nutrition Board of the Institute of Medicine, National Academy of Sciences, for less than a 28-day average for the available patient diets. RD stated the company who provided the menus could not provide a nutrient analysis for some of the therapeutic diets and it was very difficult to get any nutrient analysis from them. RD also explained the Diet Manual (a resource which reflects information for the diets served) from the company who provided the menus was not being used and an older Diet Manual from a different company was in use.

During an interview, on 9/26/24 at 10:40 am, the Director of Nursing (DON) stated, that the average length of stay was 4.0 for the past six months.

Review of the undated "Position Description Registered Dietitian," showed the Dietitian provided consultation to the facility for the purpose of providing nutrition care which will result in optimal health of the patients. The RD will work with the Certified Dietary Manager to meet the nutritional needs of the organization and the Food and Nutrition Services Department. Responsibilities include but are not limited to approves menus.

This is a repeat finding from a recertification survey conducted by the Department in 2017, and 2012.

2. Review of the Policy and Procedure titled, "Food & Nutrition in a Disaster Plan Policy # DIA021" revised 8/20/24, showed the Hospital will meet the nutritional needs of patients while sheltered in place, or evacuated to other locations. The Plan showed shelf stable menus for "Regular, Puree, Diabetic, and Low Sodium" diets.

During an interview, on 9/24/24 at 10:45 am, the RD stated she was not aware of a nutrient analysis for the disaster menu to show the menu met the nutrient needs of patients.

3. Review of the Policy and Procedure titled, "Food & Nutrition in a Disaster Plan Policy # DIA021" revised 8/20/24, showed the Hospital will meet the nutritional needs of patients while sheltered in place, or evacuated to other locations. The therapeutic menus available according to the disaster plan included "Regular, Puree, Diabetic, and Low Sodium".

During an interview, on 9/24/24 at 10:45 am, the RD confirmed a Renal diet was not part of the disaster plan.

During an interview, on 9/25/24 at 10:43 am, RD stated it may not be safe for a patient prescribed a Renal diet, to receive a different diet. RD stated the level of nutrients in the food provided, such as protein, potassium, and phosphorous might need to be adjusted.

Based on interview, and record review, the facility failed to ensure all policies were reviewed at least biennially (every two years).

This failure had the potential for facility staff to follow policies that did not reflect the most current standard of practice, thereby compromising patient care, health and safety which could lead to negative clinical outcomes.


Findings:


During an interview, and document review, on 9/25/24 at 4:15 pm, the Dietary Services Manager (DSM) provided requested policy and procedures related to issues found in the kitchen (Cross-reference C-914, and C-1208) titled, "Proper Food Handling", "Cleaning Schedules/Procedures," "Freezer Storage," and "Pest Control." The policy and procedures provided did not have an approval date. The DSM stated, that currently there were no approved policy and procedures for Food and Nutrition Services because they were being updated. The DSM explained, that the unapproved policy and procedures she provided might contain information that was not current.

A review of the policy and procedure titled, "Policies & Procedures: Development, Revision & Approval" approved 11/6/23, showed that the [Hospital] develops and continually maintains Policies and Procedures and Policy and Procedure manuals as appropriate to the operation of the facility and associated enterprises. Policies and Procedures are the blueprint for directing all aspects of patient care, employee relations, departmental responsibilities... Each department manager is responsible to develop and maintain departmental Policies and Procedures, which reflect the department's standards of performance. All Policies and Procedures will be in a standardized format. Policies and Procedures pertaining to the Critical Access Hospital and its associated services... are reviewed and routed through a multidisciplinary Policy and Procedure/Forms Committee which meets on a regular basis.

Based on interview, and record review, the facility failed to adequately assess pain relief after interventions for one (Patient 34) of six sampled patients.

This failure had the potential to allow Patient 34 to remain in pain and suffer near the end of his life, at a time when he was unable to meaningfully communicate his needs.


Findings:


A review, of the undated facility policy titled, "Pain Management," which indicated that emphasis would be placed on improving the outcomes of pain management including comfort, side effects, complications and patient satisfaction. A measure of pain intensity was to be assessed and documented in the electronic medical record, including after each pain management intervention once sufficient time has elapsed for the treatment to reach peak effect (or not greater than one hour after interventions). Pain intensity would be measured using pain scale tools of 0 to 10 with 0 indicating the absence of pain and 10 indicating the worst or most severe pain. All interventions are to be documented and evaluated by reassessment of pain score for effectiveness of the intervention.

Patient 34's medical chart was reviewed. A History and Physical dated 6/18/24, indicated that Patient 34 was admitted with respiratory syncytial virus (RSV, a virus that infects the lungs, throat and nose and can affect breathing), congestion and fever. Patient 34's medical history included atrial fibrillation (a disorder of the heart that effects its ability to pump normally), chronic kidney disease (decreased functionality of the kidneys, the organs that clean the blood of toxins and waste), chronic obstructive pulmonary disease (a group of inflammatory lung conditions that obstruct airflow and make it hard to breathe), chronic anemia (a long-term condition in which abnormal or insufficient numbers of red blood cells are unable to meet the demands of the bod), Parkinson's disease (a progressively worsening disorder caused by degeneration of nerve cells in the part of the brain), and dementia (a progressive decline in thinking, behavioral and social skills that affects a person's ability to function) from previous cerebral vascular accidents (a condition that occurs when blood flow to the brain is interrupted which can lead to damage of brain tissue).

A review was made of a discharge summary by Medical Doctor (MD) 1, dated 6/25/24 at 4:01 pm, which indicated Patient 34 had been refusing care, his condition was discussed with his durable power of attorney representative (a person authorized to act on the patient's behalf when they are unable to communicate), and the decision was made to provide comfort care (a type of medical care focusing on comfort and quality of life for patients near the end of their life) measures until he passed.

A review was made of Patient 34's pain management care plans. Outcomes included, "achieve appropriate pain score at or below the patient's pain management goal," and, "numeric pain score (0-10) expectation 4 or 3 or 2 or 1 or 0."

A review was made of Patient 34's physician's order dated 6/25/24 at 2:58 pm, by MD 2 for morphine (a controlled, potent narcotic pain reliever) 4 milligrams (mg) IVP (injected into the vein) given every two hours as needed for pain or air hunger (the sensation of severe breathlessness).

A review was made of Patient 34's pain assessment performed on 6/25/24 4:14 pm, using the FLACC pain scale (a behavioral pain assessment tool to evaluate pain in nonverbal persons, usually children, in which points are assigned for various behaviors and movements as indicators of discomfort); the scoring total assigned was level "5".

A review was made of Patient 34's medication administration record dated 6/25/24 4:15 pm, when morphine 4 mg IVP was administered by Registered Nurse (RN) A for a FLACC score of "5", indicating moderate pain.

A review was made of Patient 34's medication administration follow-up entered on 6/25/24 at 5:08 pm, in which RN 6 indicated "yes," that medication was effective, and symptoms improved, but no pain score was entered indicating how effective the medication was, and therefor there was no clarity that Patient 34's pain was adequately treated or if more interventions were needed to keep him comfortable.

A review was made of Patient 34's pain assessment performed on 6/25/24 6:15 pm, using the FLACC pain scale for a pain assessment score of "8", indicating severe pain.

A review was made of Patient 34's medication administration record dated 6/25/24 6:15 pm, when RN 4 administered morphine 4 mg IVP.

A review was made of Patient 34's medication administration follow-up entered on 6/25/24 at 7:13 pm, in which RN 4 indicated "yes," that medication was effective, but no pain score was entered indicating how effective the medication was.

During a concurrent interview, and record review, on 9/25/24 10:25 am, the Director of Nurses (DON) stated, if you have a pain level "8" but it's improved to only a "7" there is still pain. If that's outside the patient's threshold for pain tolerance, then more interventions would still need to be completed which needs a pain intensity score for a basis of comparison.

Based on observation, interview, and facility document review, the facility failed to maintain a clean and sanitary environment for the kitchen and the disaster food storage area, and prevent potential cross-contamination (the transmission of infection from a contaminated source to an uncontaminated party) as evidenced by:

1. Lack of maintaining the kitchen free of flies;
2. Lack of maintaining cabinets and shelving free of peeling paint in food preparation and food equipment/utensil storage areas;
3. Lack of maintaining clean cabinets/shelving for food preparation and service equipment;
4. Lack of maintaining clean food storage racks in the walk-in refrigerator;
5. Lack of maintaining the walk-in refrigerator floor smooth and easy to clean;
6. Lack of maintaining the ceiling over the food preparation area, in good condition;
7. Lack of maintaining an outside food grease storage container free of grease and food particles on the outside surface;
8. Lack of maintaining stored disaster food 6 inches off the floor;

These failures had the potential to create negative health outcomes for patients, staff, and visitors.


Findings:


A review, was made of a facility policy and procedure titled, "Infection Prevention Control (IPC) Plan" revised 3/13/24, which described a systemic, coordinated approach to reduce the risks of infection transmission via multiple methods, including the maintenance of a sanitary environment, monitoring areas such as food storage, preparation, refrigerators, and the mitigation of risks associated with patient infections, whether present upon admission or acquired while in the facility.

1. An observation, in the kitchen and concurrent interview, with the Dietary Services Manager (DSM) on 9/23/24 at 12 pm, showed at least three active flies in the food preparation area. In addition, there were multiple active flies, outside close to the back door of the kitchen, and when the door was opened to walk through, a fly entered the kitchen. DSM stated an insect barrier was needed for the back door and there was a plan to add an air curtain to prevent flies from entering the kitchen.

During an interview, on 9/24/24 at 8:15 am, Facilities and Engineering Staff (FES) stated, that he was aware of the need for an insect barrier for the kitchen back door. FES stated, that he could install an air curtain (a downward-facing blower fan mounted over an entrance of a building to prevent air, contaminants, or flying insects from moving inside) from on the back door but he was very busy and did not have time, and parts were not ordered yet.

A review, of the Environmental Tours Checklist dated July 29, 2024, showed flies were found and consider an air curtain at the back door.

During an interview, on 9/26/24 at 9:50 am, the Infection Preventionist (IP) stated, that the presence of flies in the kitchen could have been addressed "sooner," such as the installation of an air curtain. IP stated when FES was aware of the fly issue, parts could have been ordered for the air curtain.

According to the 2022 Federal Food Code, the premises shall be maintained free of insects. The presence of insects shall be controlled to eliminate their presence on the premises.


2. During an observation in the kitchen, and concurrent interview, with DSM on 9/23/24 at 12:10 pm, showed the shelving above a food preparation table, was painted and the paint was peeling. In addition, in the center of the kitchen were drawers and cabinets which held cooking equipment and utensils. The drawers and cabinets were painted and had peeling paint. The surface of the drawers and cabinets, where the paint was peeling, were sticky to the touch. DSM confirmed the paint on the shelving, drawers, and cabinets were peeling and stated the paint was touched up in May, but it was peeling again.

During an interview, on 9/23/24 at 3:15 pm, DSM stated, that she did weekly kitchen inspections, and the Registered Dietician (RD) did monthly kitchen inspections and were documented on a sanitation checklist. DSM's inspection checklists for the month of August and September were requested. Also, RD checklists for the past four months were requested.

Review of the "Kitchen Sanitation Checklist" completed and signed by DSM on 8/2/24, 8/8/24, 8/16/24, 8/23/24, 8/29/24, 9/6/24, 9/12/24, and 9/20/24, showed painted surfaces had chips on each of the checklists.

During an interview, on 9/24/24 at 8:40 am, FES stated, that he just painted the shelving, cabinets, and drawers in the kitchen about six months ago. FES stated he was aware the paint was currently peeling, and the peeling paint was observed in the last Environment Tour about 1.5 months ago (FES could not recall the exact date).

During an interview, and document review, on 9/24/24 at 10:45 am, the RD stated she did an inspection once a month and she documented chipping paint on her monthly sanitation checklist for the kitchen. Four of RD's most recent "Kitchen Sanitation Checklist" dated 5/21/24, 6/25/24, 7/30/24, and 8/20/24, showed painted surfaces had chips.

During an interview, on 9/26/24 at 9:30 am, the Director of Operations (DO; DSM's Supervisor) stated she did not see the sanitation checklists from DSM, or the RD.

During an interview, on 9/26/24 at 9:50 am, IP stated she did not see the sanitation checklists from DSM or the RD.

According to the 2022 Federal Food Code, nonfood-contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of corrosion-resistant, nonabsorbent, and smooth material. In addition, equipment must be designed and constructed to be durable and capable of retaining their original characteristics. Equipment must be designed and constructed so that parts do not break and end up in food as foreign objects.



3. An observation in the kitchen, and concurrent interview, with DSM on 9/23/24 at 12:15 pm, showed cabinets in the center of the kitchen holding serving and cooking utensils and equipment. There were patches of dried, yellowish residue on the surface of the shelving. There was also a significant among of brown debris resembling small wood chips on the surface of the shelving. DSM stated the shelving inside the cabinets were dirty.

During an interview, with DSM and Kitchen Staff 1 (KS1) on 9/23/24 at 3:18 pm, DSM stated the cabinets were on the cleaning schedule and the cleaning was signed off by KS1 over the weekend on 9/21/24, and 9/22/24. DSM stated the shelving inside the cabinets did not appear they were cleaned over the weekend despite the cleaning being signed off. KS1 stated she used soapy water and sanitizer to clean the surface of the cabinet shelving. KS1 also confirmed, that she signed off the cleaning of the cabinets on 9/21/24, and 9/22/24, but she did not clean the cabinets on 9/21/24, and 9/22/24. KS1 stated it was a busy weekend, so she did not get to it. DSM stated she trained staff to sign off on the cleaning schedule even when tasks were not done so there were no blank and unsigned spaces. Then KS1 stated she did not know the cabinets were not cleaned over the weekend.

During an interview, on 9/24/24 at 10:45 am, the RD stated she looked at log documentation in the kitchen when she did her monthly sanitation checklists. RD stated it was fraudulent activity to intentionally document inaccurate information.

According to the 2022 Federal Food Code, nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, an other debris. In addition, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. The 2022 Federal Food Code Annex explains cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. A regular cleaning schedule should be established and followed to maintain the facility in a clean and sanitary manner.


4. An observation in the kitchen, and concurrent interview, with DSM on 9/23/24 at 12:06 pm, showed food storage racks located inside the walk-in refrigerator with white and brown, rough to the touch, residue build-up on the wire surface of the racks. DSM confirmed there was residue build-up on the racks and stated kitchen staff were responsible for cleaning them. DSM stated the racks were removed and washed down. DSM also stated it was part of a plan of correction from a survey in May, to replace the racks.

During an interview, on 9/23/24 at 3:15 pm, DSM stated the food storage racks located in the walk-in refrigerator were cleaned monthly, but were not on the cleaning schedule, so there was no documentation to show when they were last cleaned. DSM stated the racks should be cleaned prior to the monthly cleaning if they became dirty. DSM stated if the racks were dirty before the monthly cleaning, she documented the dirty racks on her weekly inspection checklist. DSM stated the RD and her supervisor (the Director of Operations), received her weekly sanitation checklists. The inspection checklists for the month of August and September were requested.

Review of the "Kitchen Sanitation Checklist" completed and signed by DSM on 8/2/24, 8/8/24, 8/16/24, 8/23/24, 8/29/24, 9/6/24, 9/12/24, and 9/20/24. Each of the checklists were marked "no" for the section refrigerator "shelves, racks, walls, floors, ceiling and doors clean."

During an interview, on 9/24/24 at 8:47 am, DSM stated when she documented on the checklist "no" for refrigerator shelves, racks, walls, floors, ceiling, and doors clean, it meant the entire refrigerator was in poor condition including the racks.

During and interview, on 9/24/24 at 10:45 am, the RD stated she was aware of residue build-up on the food storage racks located in the walk-in refrigerator, but she did not document the residue build-up recently on her monthly sanitation checklist.

During an interview, on 9/25/24 at 1:25 pm, despite the poor condition of the walk-in refrigerator racks, DS confirmed nothing was documented about the walk-in refrigerator on the last Environmental Tour Checklist dated July 29, 2024.

During an interview, on 9/25/24 at 2:37 pm, DSM stated during the Environmental Tour it was difficult to discuss all the issues in the kitchen due to so many people on the Environmental Tour team looking at different areas at the same time. She stated she was pulled in different directions and did not get a chance to discuss the condition of the walk-in refrigerator.

According to the 2022 Federal Food Code, materials that are used in the construction of food-contact surfaces of equipment shall be durable and corrosion-resistant under normal use conditions and shall have a smooth and cleanable surface. Food contact surfaces shall be clean to sight and touch. Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, an other debris. In addition, nonfood-contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of corrosion-resistant, nonabsorbent, and smooth material.


5. An observation in the kitchen, and concurrent interview, with DSM on 9/23/24 at 12:06 pm, showed the floor inside the walk-in refrigerator had residue build-up and debris in a half-inch gap along the floor and the metal threshold/transition strip.

During an observation, and interview, on 9/24/24 at 8:40 am, FES confirmed there was a gap in the walk-in refrigerator floor and stated the floor was corroded. FES stated he was aware of the poor condition of floor and the floor needed to be replaced..

Review of the "Kitchen Sanitation Checklist" completed and signed by DSM on 8/2/24, 8/8/24, 8/16/24, 8/23/24, 8/29/24, 9/6/24, 9/12/24, and 9/20/24, showed each of the checklists showed were marked "no" for the section refrigerator "shelves, racks, walls, floors, ceiling and doors clean."

During an interview, on 9/24/24 at 8:47 am, DSM stated when she documented on the checklist "no" for refrigerator shelves, racks, walls, floors, ceiling, and doors clean, it meant the entire refrigerator was in poor condition including the floors.

During an interview, on 9/24/24 at 10:45 am, the RD stated she was aware of the poor condition of the walk-in refrigerator floor but did not document about the refrigerator floor on her monthly sanitation checklist.

During an interview, on 9/25/24 at 1:25 pm, despite the poor condition of the walk-in refrigerator floor, DS confirmed nothing was documented about the walk-in refrigerator on the last Environment Tours Checklist dated July 29, 2024.

During in interview, on 9/25/24 at 2:37 pm, DSM stated during the Environmental Tour it was difficult to discuss all the issues in the kitchen due to so many people on the Environmental Tour team looking at different areas at the same time. She stated she was pulled in different directions and did not get a chance to discuss the condition of the walk-in refrigerator.

According to the 2022 Federal Food Code, floor surfaces under conditions of normal use shall be smooth, durable, and easily cleanable for areas where food establishment operations are conducted.


6. An observation in the kitchen, and concurrent interview, on 9/24/24 at 8:45 am, showed an open crack in the ceiling above a food preparation table. FES stated he was aware of the crack which he observed during the last Environment tour.

During an interview, and document review, on 9/24/24 at 10:45 am, the RD stated she did document the cracked ceiling on her last monthly sanitation checklist. RD's checklist dated 8/20/24, was marked "no" under the Maintenance section for "All floors, walls, ceiling tiles in place and not cracked". "Cracked" was circled by RD.

During an interview, and document review, on 9:25 at 9:10 am, the of the "Environmental Tours Checklist" dated July 29, 2024, showed "visible leak with the ceiling material bubbling up". FES confirmed this documentation was for the crack observed in the ceiling. It was noted this project was not assigned to anyone and the plan of correction showed "working with maintenance".

According to the 2022 Federal Food Code, materials for indoor ceiling surfaces under conditions of normal use shall be smooth, durable, and easily cleanable for areas where food establishment operations are conducted.


7. An observation, and concurrent interview, with DSM on 9/23/24 at 11:58 am, showed a metal container two feet deep and four feet in length, located outside the backdoor of the kitchen. The top surface of the container appeared greasy and had brown particles resembling fried food crumbs. DSM stated this metal container held used cooking grease from the kitchen. DSM stated the kitchen staff opened the lid to the box and poured the grease into the container. DSM confirmed there was grease and food particles on the top surface and stated maintenance cleaned the area.

An observation, and concurrent interview, on 9/24/24 at 8:15 am, showed the metal grease container was still greasy with food crumbs on the top surface. FES stated facilities (maintenance) did not really maintain the area, and stated it was "dietary" responsibility.

During an interview, with IP and DS on 9/25/24 at 1:50 pm, IP stated the Environmental Tour did not include going outside behind the kitchen. IP stated food grease and particles could attract "critters." DS stated the metal grease container was always greasy on the outside surface.

According to the 2022 Federal Food Code, soiled receptacles and waste handling units for refuse shall be cleaned at a frequency necessary to prevent them from developing buildup of soil or becoming attractants for insects and rodents.

8. During an observation, and concurrent interview, on 9/26/24 at 11:30 am, disaster food was observed in an outside storage area. The bottom shelf was 2.5 inches off the floor and held food such as cases of dried cereal and cans of food. DSM confirmed the food was stored 2.5 inches off the floor and it should be stored at least 6 inches above the floor.

According to the 2022 Federal Food Code, Food shall be protected from contamination by storing the food at least 6 inches above the floor.