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Based on observations, staff interview, and record review, the facility failed to:
- prepare food in a sanitary environment,
- ensure that non-food contact surfaces of equipment was sanitized properly,
- ensure that all food preparation equipment was cleaned thoroughly and stored properly in between use,
- ensure proper storage of clean kitchen equipment and utensils,
- ensure all foods containers and packages were properly marked with open dates,
- discard expired food items,
- discard opened, undated, unsealed food items in the freezers and coolers,
- ensure use of a standardized menu system and recipes,
- ensure proper hand hygiene and glove change with contamination
- ensure that kitchen operations were performed by highly trained kitchen staff.

Refer to A-0619, A-0620, A-0628, and A-0701 for further description of the listed violations.

Based on observation, staff interview, and record review, the facility did not ensure food was stored, prepared, and served under safe and sanitary conditions. Findings include:

1. On 3/14/12 between 2:10 p.m. and 5:10 p.m., the surveyor conducted the following observations and staff interviews in the main kitchen:

A) Staff Hygiene, Handwashing and Food Handling

-- Staff members A, B, D, E, and F had inadequate and partial hair coverage/restraint (bangs and side hairs were exposed) when observed actively preparing and serving foods in the kitchen between 2:10 and 5:10 p.m. at the time of the entire observation duration.

-- At 2:25 p.m. staff member B was observed leaving the first walk-in cooler with her gloved hands, she walked to a production counter, and started cutting fresh green peppers. She didn't perform hand hygiene (remove gloves, wash hands and reglove with a fresh pair of gloves) before starting the new task of cutting fresh vegetables. Staff member B's hair was not completely restrained while she was actively preparing food. Staff member B told the surveyor that the sliced fresh vegetables were for the oriental chicken salad for tomorrow night.

-- Staff member H, was observed walking around the kitchen in her street clothes and without a hair restraint. She told the surveyor that she was not working that day. Staff H hugged staff B who was slicing vegetables, then walked through the kitchen with her water/coffee cup in hand, and entered the cafeteria area, and talked with staff members D and F; she then walked back through the kitchen. She put her Styrofoam water/coffee cup on the counter next to the fresh vegetables where staff B was slicing them. She contaminated the counter with her drinking cup, put her coat on, and left the kitchen.

-- At 2:30 p.m. staff member A was observed helping staff member B cut vegetables. Staff A had partial hair restraint, her curly bangs and hair on the sides of her head were exposed. She left the area, took gloves off and did not perform hand hygiene. Staff member A had nail polish on her fingernails. Staff member A then took temperatures of the ham, yams, and the asparagus in the Combo Retherm unit. She wiped her nose on her left forearm. She regloved and returned to slicing peppers with staff member B. Staff A left the station briefly, picked up a dry kitchen towel with her gloved hands, placed it under the cutting board and continued to slice peppers with the same gloved hands. Staff member A next answered the ringing phone, took her gloves off, took an order (handled a pen and a note pad), wiped her nose with her right index finger, walked to the cafeteria, retrieved a piece of tape and taped the order on the sneeze guard. She washed her hands in the cafeteria and came back into the kitchen. Staff member A handled some papers, near the phone, handled the menus, wiped sweat on her forehead with her right hand fingers and answered the ringing phone again. Staff member A contaminated foods and many surfaces in the kitchen with her contaminated gloved and bare hands creating potential to spread her illness.

-- Staff member F was observed donning gloves without washing her hands first. She was helping staff member E taking temperature of a cheese sauce cooking in the microwave. Staff member E also donned gloves without washing her hands.

-- Staff member B was observed glove changing without hand hygiene when she left her task of slicing vegetables; she then came back and continued slicing yellow peppers. She had nail polish on her fingers.

-- At 4:12 p.m., staff member F who was on a break sitting in the cafeteria, came behind the service line in the cafeteria, donned gloves and served a patron his dinner. She didn't wash her hands prior to donning gloves.

-- At 4:15 p.m., staff member B and staff member E donned gloves while setting up the trayline for the evening meal service. Neither of them washed their hands before donning gloves. They assembled the clients' food trays. She changed gloves but didn't wash her hands in between glove change during meal service.

-- Staff member A was observed sneezing several times into her elbow, or bending over and out from the kitchen door and sneezing into the High Bay storage without covering her mouth, and sneezing in the first walk-in cooler since the beginning of the observations in the kitchen.

-- At 4:31 p.m., staff member A observed donning gloves without first handwashing. She then organized Styrofoam bowls in trays. She then entered the first walk-in cooler with the same gloves on, came out wheeling a cart housing the pans of recently sliced vegetables, and started assembling bowls of salads. First, she dished the cucumbers and the broccoli with her gloved hands , not using a utensil. Then she left her station, walked over to the trayline, stirred the yams in trayline where staff members B and E were dishing food, came back to the station, and continued handling the sliced vegetables with the same gloves. Staff member A took her gloves off and left the station. She pulled a small paring knife from her pocket, rinsed it at the 3-compartment sink and came back and placed it on a plate next to staff member B at the trayline. She then dried her hands on a towel sitting on the counter below the phone, opened a couple of drawers below the counter, stated to the surveyor that she was looking for the sanitizer strips. She handled several items in the drawers; with the help of staff member D, they found the small container of sanitizer strips. Staff member A then regloved without washing her hands and continued assembling the salads for the next day's meal.

-- One client walked into the kitchen at 5:00 p.m., he had no hair restraint. He told the surveyor he was a dishwasher.

C) Food Service and preparation equipment

-- A pan of garden burgers were being thawed on a utility cart at room temperature. Staff member E stated they were for dinner tonight.

-- Staff member C, dishwasher, told surveyor that she had not been trained to use the sanitizer strips.

-- Surfaces around the walk-in cooler handles were covered with sticky finger prints.

-- An opened and unsealed bag of coconut shavings was observed in a storage room named C185. The date on the bag was illegible.

-- None of the clean utensils stored in pans in the room names C185 were covered between use.

-- Hobart dough mixer and the buffalo chopper were left uncovered while in clean storage. This could promote dust collection on the food contact surfaces of the equipment. Additionally, the underside of the Hobart mixer was covered with dried food particles.

-- Plates used for food service were left uncovered while stored on the trayline between use.

-- There was an opened and unsealed package of Bisquick stored in a pan with plastic souffle cups and lids in a pan on a lower shelf of the diet prep cook's area. On the same shelf, an opened and unsealed package of Uncle Ben's rice package was placed with pans and skillets towards the back of the shelf near the back wall. The small food fryer was being stored food surface exposed with 3 food surface exposed skillets on the same counter. The counter had crumbs and dust, indicating other food cooking equipment had potential for dust collection.

-- The following were observed in the Dairy cooler:
-- undated and unlabeled plastic container of graded parmesan cheese;
-- an opened but undated 1/2 gallon container of whole milk;
-- an opened container of Tzatziki sauce was dated "3-8" however, manufacturer's stamp read "062311". There were total of 4 containers of Tzatziki sauce in the cooler, 3 of them had not been opened, but were outdated also;
-- A gallon of mayonnaise container was not marked with an open date, it was half consumed. No other use by dates were identified on the container;
-- a large unsealed bag of mixed nuts;
-- an unsealed and undated, half full, 4-quart container housing unidentified food substance (appeared to be tartar sauce);
-- the food storage shelves were rusty in places allowing them to be potentially unclean and sanitary.

2. On 3/15/12 between 7:30 a.m. and 9:45 a.m., the surveyor conducted the following observations and staff interviews in the main kitchen and in the FSM's office:

-- Staff member L was observed walking through the kitchen with gloves on, touching several surfaces in the main kitchen and in the cafeteria including, his nose and his hat; he left the kitchen and returned, entering the cafeteria, the walk-in cooler, wiping the beverage line in the cafeteria, and serving food wearing the same gloves during the entire observation.

-- The interior (ceiling) of the microwave was covered with dried food splatter, which was in the same condition as thew previous day.

-- Two wet kitchen towels were observed in the cafeteria, one was left on the counter next to the fan, and the other on the counter by the beverage line. There was no sanitizer bucket set up for immersing kitchen towels in between uses in the cafeteria.

-- One client worker next to the 3-compartment sink had a hat on but his long hair was hanging out the hat. He was washing dishes that morning.

-- Staff member O had partial hair restraint only.

3. Record review provided by staff member I indicated that the kitchen staff had received two inservice trainings from the director of nursing on hand washing and safe food handling, one dating 1/9/12 and the other dating 2/10/12. Per record review, of the kitchen staff observed on 3/14/12 and 3/15/12, only staff member A and staff member B had attended the above inservices.

4. According to ARM37.110.210 Food Employees, 7. (b) "Unless wearing intact gloves in good repair, a food service employee may not wear fingernail polish or artificial fingernails when working with exposed food."

Based on observation, record review, and staff interview, the facility food service manager did not ensure the kitchen staff were comprehensively trained and oriented to the policy and procedures of daily kitchen operations. Findings include:

On 3/14/12 at 4:00 p.m., staff member E was questioned about the labeling/dating food containers and discarding of left overs. She stated she did not know who was accountable for discarding left overs and when they were to be discarded. She said she checked the dates on the foods, but she was not sure when left overs were discarded. After further questioning, staff member E stated she was not trained in the kitchen policy and procedures.

Staff member E also did not know the policy and procedures on how use the 3-compartment sink. She stated the clients used these sinks mostly. She said they sometimes filled the third sink (sanitizer sink) with the sanitizer completely and sometimes only half and added more tap water. She did not know the location of the chemical sanitizer concentration strips (the strips are used in commercial kitchens to test the sanitizer concentrations in dish machines and in 3-compartment sinks to ensure the maintenance of the sanitizer concentration throughout the task).

Review of the Individual Training Report of staff member E revealed that since 6/11, she attended a dietary training only once on 6/1/11 for food temperature monitors and uniform requirements. Review of all of the dietary staff Individual Training Reports revealed that the only documented training in all of the kitchen staff employee files was the 6/1/11 training on food temperature monitors and uniform requirements. These records were provided to the surveyor by staff member I at 9:50 a.m. on 3/15/12.

On 3/15/12 at 9:00 a.m. staff member K, FSM, was asked to discuss the new and existing staff training and orientation process. Staff member K, stated a standard safety checklist on how to operate the equipment along with review of the MSDS manual were the only training provided to the new staff. After that time, they received on the job training with another staff member. Staff K stated the kitchen policy and procedures were computerized. Staff K did not provide any evidence that the staff was trained in the kitchen policy and procedures.

On the late afternoon of 3/14/12 and the early morning of 3/15/12, approximately 7 dietary staff demonstrated poor self hygiene, poor hand hygiene, unrestrained hair while preparing and serving food, improper food storage, lack of properly sanitized food equipment and kitchen environment, and lack of dietary policy and procedure knowledge. (See A-0619)

Additionally, staff member K was asked to discuss the training of the client workers in the kitchen. She did not provide any documentation or any evidence that the client workers were trained in kitchen tasks. Staff K agreed that this was lacking for the client workers.

On 3/15/12 at 8:30 a.m., one female client was observed collecting a bucket and towels to wipe the cafeteria tables and chairs. She neither applied a hair restraint nor washed her hands when she entered the kitchen.

On 3/15/12 at 8:35 a.m., two male clients were observed washing dishes at the 3-compartment sinks. When asked to discuss the sanitizer solution concentrations (quaternary ammonium compound - 200 ppm) and immersion durations (30 seconds) for proper sanitation of the dishes, the clients indicated they did not know.

On 3/15/12 at 9:15 a.m., staff member J, RD, stated the training had been problematic due to high staff turnover.

Based on observation, record review, and staff interview, the facility lacked a standardized menu system that included recipes and the nutritional analysis for all menu items and the physician ordered diets. Findings include:

On 3/14/11 at 2:15 p.m., staff member G, RD, was asked to provide the therapeutic menus along with their nutritional analysis information for the current week. She stated they did not have nutritional analysis of the therapeutic diets. She stated they used the Montana State Prison (MSP) menus and only the regular diets had the nutritional analysis information. However, they had not always served the same foods indicated on those menus, therefore, they could not use the nutritional analysis information provided by the MSP menus. Staff G indicated that she had started working for the hospital about a month ago and she assumed the task of analyzing the menus.

On 3/15/12, when staff member J was asked calorie levels of regular diets, he said "I don't know". He was then asked the calorie levels of NAS diets, he said "I don't know". He also stated nutritional analysis of therapeutic diets were not needed. He stated not daily but the overall weekly intakes of the clients were important, but when asked what that was he said "I don't know". The management staff including two registered dietitians and the FSM had no specific knowledge of the estimated macro nutrients (carbohydrates, fats and protein) and micro nutrients (vitamins and minerals) provided by the current 3-week menu cycles. The current physician's ordered therapeutic diets for the clients were NAS, no concentrated sweets, finger foods, low fat/low cholesterol, mechanical soft and pureed diets. The facility additionally provided 1500, 1800 and 2200 calorie diets. There were no menu extensions for these calorie restricted diabetic diets. One client had a gluten free diet order, but the 3-week menu cycle did not include a gluten free diet extensions for menu choices.

On 3/15/12 at 8:35 a.m., staff member N stated that they were serving beef tips over fettuccini for the noon meal that day. However, he had one client with no onions, one with no gluten, and two clients with no mushrooms. He said "my job is that I have to figure out what to give them for lunch, since they can't have the beef tips", and further added he had to go see what they had in the cooler. He said this was because the food came from the prison already prepped and they didn't prep the therapeutic diets. He said the beef tips prepared at the prison had the flour, onions and the mushrooms. He said they did not have the recipe to make the gluten, onion and mushroom free version of the beef tips.

In summary, the menus were not standardized to provide the same food options to all of the clients throughout the facility including the recipes that reflected the individualistic alterations for physician ordered special diets. The menus lacked standardized recipes on all of the foods prepared including the mechanical soft and pureed diets. This could result in a finished product that could taste differently with different ingredients and different nutritional value when prepared by different staff members.

Without the analysis of the macro and micro nutrients breakdown information, one could not determine the approximate nutritional and therapeutic value/indicators of the foods served to the clients. The menus did not have complete therapeutic extensions to guide the cooks as to what to prepare and serve for all of the physician ordered therapeutic diets and diet combinations. There was no evidence that the cooks had given the necessary guidance and education on preparing a uniform product every time. There was no evidence that cooks were given guidance on what and how to prepare gluten free menu choices that were similar to the current menu options.

Based on observations and staff interview, the facility did not ensure that the kitchen staff promoted a sanitary kitchen environment. Findings include:

On 3/14/12 starting at 2:10 p.m., the following concerns were observed in the main hospital kitchen:

-- At 2:45 p.m., one of the fire rated ceiling tiles, measuring 2 ft. x 2 ft., was missing above the hand washing sink in the main kitchen. When asked, staff member A stated that it was off the track for "about a month". She said the maintenance staff was working on a leak a while back.

-- At 3:15 p.m., anti-slip stickers covering the dish room floor tiles were chipped, with edges rolled off the floor (creating trip hazard as well), and with missing edges, creating uncleanable surfaces. Black matter and dirt were accumulated along the rugged and uneven edges of the stickers.

-- At 3:22 p.m., the floor along the cove base under the cook's range/oven unit had a heavy accumulation of food stuff and black matter.

-- At 3:23 p.m., the baffle filters in the kitchen hood had heavy accumulation of grime and grease.

-- At 3:30 p.m., the lower shelves of the stainless steel counters (where clean pots and pans were housed) had food crumbs and dust.