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Based on interview and record review, the facility failed to ensure its facility-wide Quality Committee actively participated in the development of the facility's institutional plan for a major construction project for four of five shower rooms on the sixth floor of the main hospital (Facility A). Facility A's four out of five shower rooms on the sixth floor had remained closed since 4/28/2022, when water was seen leaking through the shower stall floors to the level beneath (fifth floor).

The deficiency had the potential to cause a delay in Facility A's ability to manage and resolve the long-standing issue of leaking shower stalls on the sixth floor which was first identified on 4/28/2022 (one year ago).

Findings:

A review of the meeting minutes (written record of what was said at a meeting) of the Facility A's Governing Board (GB) from the preceding twelve months (April 2022 to March 2023) indicated the documents had no information on the GB's knowledge of or involvement in the hospital's management of the sixth-floor shower issue (leaking shower stalls) in any of the meeting minutes since 4/28/2022.

A review of the hospital's Quality Council (QC, council that involves the Environmental of Care Committee [EOC, committee whose activities include managing environmental safety of patients, staff, and visitors, hazardous materials, utilities, and fire safety]) meeting minutes from the preceding twelve months (April 2022 to March 2023) indicated the meeting minutes had no documentation relating to the sixth-floor shower issue (leaking shower stalls) in the minutes since 4/28/2022.

On 4/26/2023 at 2:45 p.m., during an interview with the Vice President (VP) of Facility Development, the VP stated the EOC committee reports to the Quality Council, which in turn reports to the Governing Board.

On 4/28/2023 at 10:45 a.m., during an interview with the facility's Chief Operating Officer (COO), the COO reported four out of five shower rooms on the sixth floor had remained closed since April of last year when water was first seen leaking through the shower stall floors to the level beneath (fifth floor). The COO explained that the issue (leaking shower stalls) was later found to be due to an underlying structural problem caused by a sloping floor of the shower stalls. The COO stated the issue proved larger and more complex than initially thought. Facility A learned the issue (leaking shower stalls) was a major reconstruction, and not just a repair, of the shower stalls was necessary to fix the problem.

On 4/28/2023 at 10:45 a.m., during an interview, the COO stated the lack of documentation in the meeting minutes of the hospital GB and the QC of their knowledge of or active involvement in the leaking shower stalls on the sixth floor was discussed with the COO. The COO stated she does not know what information was contained in those minutes, but that she presents regular updates to the GB on the current state of the facility's operations. The COO added that updates were often provided in the form of email communications to the GB.

On 4/28/2023 at 10:45 a.m., during an interview, the COO further stated that the shower problem was being addressed and discussed by the facility's Environment of Care (EOC) Committee, as documented in the committee's quarterly meeting minutes. The facility did not provide evidence demonstrating that the EOC Committee was reporting this issue (leaking shower stalls) and providing updates regularly to the facility-wide Quality Committee.

On 4/28/2023 at 4 p.m., during an interview with the hospital's Interim Chief Executive Officer (CEO), the CEO stated both he and the COO give updates on any new or ongoing facility improvement projects to the GB. The CEO stated over the past several months the hospital had worked on multiple major construction projects simultaneously, including seismic refitting of all nursing stations which involved tearing down and rebuilding of entire walls of the nursing stations, replacing and installing new elevators of the main hospital (Facility A), and construction of a new emergency room, among others. The CEO stated that because multiple large projects needed to be completed at the same time, the hospital has had to prioritize to work on more pressing issues first, causing certain other projects, such as the sixth-floor shower reconstruction, to be delayed. The CEO stated the delay was also attributable to the overall complexity and magnitude of the project.

A review of Facility A's policy and procedure titled, "Plan Operations Corrective Maintenance," dated 9/2022, indicated, "The Plant Operations Department shall develop, implement, manage a corrective maintenance program. Requestors shall be kept informed about all repair status." The policy and procedure indicated, "All employees of the Medical Center shall report any repair requests for non-medical equipment failures to the Plant Operations Engineering."

Based on interview and record review, the facility failed to sustain the facility's performance improvement activities and implement a action plan and correct finding identified on the facility's Kitchen Rountine infection and food safety audit (dated 2/24/23) and the Los Angeles County retail for inspection (dated 2/24/23) for one of three surveyed facilities (Facility B) from 4/25/23 to 4/28/23.

This deficient practice resulted to findings (discoloration on the walls and debris on floor) being present on 4/25/23 inspection of Facility B's kitchen. This has the potential to result in food borne illness in patients, staffs, and visitors who consume the food prepared by Facility B's kitchen.

Findings:

A review of Facility B's Kitchen Routine infection control and food safety audit, dated 2/24/23, indicated there were signs of discoloration on walls, floors and deep cleaning was scheduled as an action plan.

A review of Los Angeles County, "Retail food official inspection report," dated 2/24/23 indicated, "Observed broken, missing tiles, and grout on wall under mechanical ware wash machine. Observed debris accumulation on floor under 3 doors reach in cooler."

A review of the Daily kitchen cleaning checklist, dated 2/27/2023 to 4/9/2023, indicated mopping and scrubbing floors was not scheduled. There was no cleaning checklist available for dates after 4/9/2023.

A review of the QAPI (QAPI- Quality Assurance and Performance Improvement-proactive approach that continuously studies processes with the goal to prevent or decrease the likelihood of problems in care delivery) reports for the kitchen (QAPI- Quality Assurance and Performance Improvement-proactive approach that continuously studies processes with the goal to prevent or decrease the likelihood of problems in care delivery) dated 1/2023 to 3/2023 indicated performance improvement measures were monitored for the temperature of the kitchen environment and timely equipment repairs. There were no performance improvement activities that addressed the deficient and non-compliant practices in the kitchen related to infection control.

During a tour of the kitchen with DFNS, on 4/25/23, at 3:00 p.m., the wall tiles or backsplash behind the stove and ice machine had brown color splashes and stains. The tiles on the floor under and around the stove had sticky stains. There was a thick layer of dust under the counter where food was served in cafeteria. There was also trash in the corners under the food service counter. The food service counter that had thick layer of dust. Paper towels was observed in the corners in between the cafeteria and kitchen food preparation area.

During an interview, on 4/25/23, at 3:00 p.m., DFNS stated the kitchen floors are moped everyday by kitchen staff. DFNS stated the cafeteria side was cleaned by environmental staff and they (environment staff) were responsible for cleaning under the food service counter. DFNS stated the facility was looking for an outside company that can provide deep cleaning services.

During an interview with Director of Engineering (DE), 4/25/23, at 4:00 p.m., DE stated the environmental department was responsible to mop floors in the cafeteria. DE stated the dust accumulation and trash under counter not acceptable.

During an interview, on 4/26/23 at 1:30 p.m., DFNS stated sanitation and infection control findings identified on 4/25/23 and 4/26/23 are not part of performance improvement project in the Food and Nutrition Department.

During an interview with Regional Director of Operations (RDO), on 4/28/23 at 11:30 a.m., RDO stated the facility was informed by the LA County Environmental Health Inspector of the cleaning issue in the kitchen during an inspection in February of 2023 that is why the facility has reached out to an outside company to provide deep cleaning services.

A review of Food and Drug Administration (FDA) food code 2022, code 4-601.11 titled, "Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils" indicated, "Nonfood-contact surfaces of equipment shall be kept free on an accumulation of dust, dirt, food residue and other debris." The FDA food code indicate nonfood such as, "CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues. The FDA food code indicated, "The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests."

Based on observation, interview and record review, the facility (Facility A and Facility B) failed to ensure that the Condition of Participation for Food and Dietetic Services was met as evidenced by:

1. Failure to ensure staff were competent in safe and effective food handling practices for one of three surveyed facilities (Facility A) from 4/25/23 to 4/28/23 when:

a.) i. Food Service Worker 1 (FSW1) was not competent to wash produce (fruits and vegetable) to correctly washing the produce according manufacturer's instructions to wash produce by first washing in water only, then submerge produce (fruits and vegetables) in produce sanitizer solution wash for 60 seconds and then drain. (Cross refer A - 0622).

a.) ii. FSW 1 did follow how to use a testing strip according to manufacturer's guideline to check the concentration of the sanitizer solution the facility used to wash the produce (fruits and vegetables). (Cross refer A - 0622).

b.) FSW 2 was competent to use the testing strip according to manufacturer's guideline to check the concentration of the sanitizer solution used in the three compartments sink to ensure the sanitizer solution was effective in sanitizing the used facility pots, pans, and trays. (Cross refer A - 0622).

2. Failure to ensure the timely monitoring of dietary intake and effective assessment of nutritional status for one of nine sampled patients (Patient 208) at Facility B by not:

a.) Implementing the Registered Dietician's recommendation for Patient 208 to start a Nutrition Supplement (Ensure Enlive [a food supplement designed to help rebuild strength and energy] three times [TID] per day on 4/19/23). (Cross refer A - 0629)

b.) Assessing Patient 208's calorie count (for three days starting 4/19/23). (Cross refer A - 0629)

c.) Monitoring Patient 208's weight loss on 4/21/23 and reevaluating new tube feeding order 4/24/23. (Cross refer A-0629)

The cumulative effect of these systemic problems resulted in the Facility A and Facility B inability to ensure the Condition of Participation for Food and Dietary Services was met.

Based on observation, interviews and record reviews, the facility failed to ensure staff were competent in safe and effective food handling practices for one of three surveyed facilities (Facility A) from 4/25/23 to 4/28/23. The Facility B to:

1. Ensure Food Service Worker 1 (FSW1) was competent to wash produce (fruits and vegetable) by:

a. Not correctly washing the produce according manufacturer's instructions to wash produce by first washing in water only, then submerge produce (fruits and vegetables) in produce sanitizer solution wash for 60 seconds and then drain.

b. Not using the testing strip according to manufacturer's guideline to check the concentration of the sanitizer solution the facility used to wash the produce (fruits and vegetables).

This deficiencies had the potential to result in fruits and vegetables not being washed adequately and result in food borne illness in a medically vulnerable patient population of patients, staff, and visitors who were served the food.

2. Ensure Food Service Worker 2 (FSW2) was competent to use the testing strip according to manufacturer's guideline to check the concentration of the sanitizer solution used in the three compartments sink to ensure the sanitizer solution was effective in sanitizing the used facility pots, pans, and trays.

This deficient practice had the potential to result in ineffectively sanitizing the pots and pans used to cook patient food and patient meal trays and cause food borne illness in a medically vulnerable patient population of patients who were served the food.

Findings:

1. a. During an observation of the produce washing area, on 4/25/23, at 1:40 p.m., Food FSW1 observed and demonstrated how to wash and test the concentration for the sanitizer solution used to wash Hospital B produce (fruits and vegetables). FSW1 stated fruits or vegetables were washed by immersing the produce in a clean container filled with the produce wash sanitizer solution. FSW 1 stated the produce was soak for about 5 minutes. FSW 1 stated after soaking, the produce was removed and rinse under water for 3 minutes. FSW 1 also stated everyone does it (produce washing) differently, but this (the demonstrated produce washing) was the method FSW 1 used.

During a concurrent interview with Director of Food and Nutrition Services (DFNS) on 4/25/23, at 1:40 p.m., DFNS stated vegetables should be soaked in the produce wash sanitizer for 1 minute and then removed.

A review of manufacturer's instructions for produce posted on the wall by the produce washing sink, undated, indicated to immerse fruits and vegetable in a sink filled with water and agitate (the act of stirring things up) to remove soil (dirt). The instruction indicated the next step was to fill a second sink with produce sanitizer solution wash and transfer the produce into the produce sanitizer solution wash sanitizer. The produce was to be submerge and agitate for 60 seconds and then drain.

b. During the observation and interview FSW1, on 4/25/23 at 1:40 p.m., FSW 1 observed and demonstrated how FSW 1 tested the concentration of the produce wash sanitizer solution. FSW 1 filled a container with the sanitizer wash and then placed the test strip in the solution. FSW1 said the test strip needs to be immersed for 5 minutes. FSW1 removed the test strip and compared the test strip to the color chart (the chart indicated sanitizer solution green in color and not in range greater than (>) 3.5 pH (potential of hydrogen [type of chemical] was a scale used to specify the acidity or basicity of a solution. Acidic solutions are measured to have lower pH values than basic or alkaline solutions) it should be yellow test strip color indicated pH less than (<) 3 .5 FSW1 said the sanitizer bottle is empty and replaced the sanitizer with a new container.

A review of manufactures direction on testing the produce sanitizer solution was indicated to dip the test strip in the solution and remove promptly to compare the test strip to the color indicator chart. Normal range in < 3.5 pH.

2. During an observation of the manual ware washing (dishwasher, washing dishes by hand) area with the Director of Food and Nutrition Services (DFNS), on 4/25/23, at 2:30 p.m., Food Service Worker (FSW 2) was washing pots and pans after lunch service. FSW2 was using the 3 compartments sink to wash the trays. FSW2 observed and demonstrated how to test the concentration of the sanitizer in the final rinse step of ware washing. FSW 2 observed and placed the test strip in the third sink of sanitizer solution for 2 minutes, and then compared the test strip to the color chart it (sanitizer solution) was > 400 parts per million (PPM) normal is (200 PPM to 400 PPM), FSW2 tested temperature of the sanitizer solution using facility thermometer and registered at 112 degrees Fahrenheit(F). FSW2 stated the temperature of the sanitizer solution was ok per Pot Sink Temp and Sanitizer Log. (Facility log used to document temperatures of wash water, rinse water, and sanitizer solution in the 3 - compartment sink)

A review of the manufacture's direction on the test strip label indicated that the sanitizer solution temperature must be tested at 65 degrees F to 75 degrees F for accuracy.

During an interview, on 4/25/23, at 2:30 p.m., DFNS stated that the Pot sink temp and sanitizer log indicated sanitizer solution temperature should be at > 75 degrees F and it (Pot sink temp and sanitizer log) should also indicate the sanitizer solution temperature for testing must be tested at 65 degrees F to 75 degrees F for accuracy. DFNS stated the temperature for testing was not clearly written. DFNS said the log (Pot sink temp and sanitizer log) was confusing for staff because its (Pot sink temp and sanitizer log) written sanitizer solution should be > 75degrees and not noting for testing the temperature for sanitizer solution was at 65 degrees F to 75 degrees F.

During an interview and concurrent review of manufactures instructions for testing on the test strip on 4/25/23, at 2:30 p.m., DFNS stated testing sanitizer solution should be 65 degrees F to 75 degrees F for accurate results and only dipped for 10 seconds.

A review of Facility A policy and procedure titled, "Sanitizing Food Contact Surfaces" revised date 1/2023, indicated, "When the concentration of the quat solution (sanitizer solution) was tested, the solution must be at the temperature indicated on the test strip package. When the solution was used, the temperature must be maintained at a minimum of 75 degrees F." The manufacture direction indicated that if, "The temperature of the quat solution was too high to test, scoop some of the sanitizer solution out in a cup to allow it to cool to the appropriate temperature before testing. The concentration of the quat sanitizing solution must be 200 PPM to 400 PPM."

A review of the job description for Food Service worker, dated 8/2020, indicated the worker, "Collect all pots and pans, ensures pot and pans are cleaned using the three compartments sink and air dried per department policy and procedures."

Based on interviews and record reviews, the hospital failed to ensure the timely monitoring of dietary intake and effective assessment of nutritional status for one of nine sampled patients (Patient 208). The Facility B failed to:

a. Implement the Registered Dietician's recommendation for Patient 208 to start a Nutrition Supplement (Ensure Enlive [a food supplement designed to help rebuild strength and energy] three times [TID] per day on 4/19/23)

b. Assess Patient 208's calorie count (for three days starting 4/19/23).

c. Monitor Weight loss on 4/21/23 and reevaluate new tube feeding order 4/24/23.


The deficient practices resulted to dietitian recommendation (a health professional who has special training in diet and nutrition.) for supplement was not communicated to physician and incomplete daily nutritional assessment for Patient 208 (4/21/23). Patient 208's had a weight loss of 25 pounds or 15% weight loss from time of admission on 4/21/23 (3 days after admission date 4/18/23).

Findings:

a. A review of Patient 208's Nursing Admission Notes, dated 4/18/23, indicated Patient 208's admission weight was 73.4 kg (kilograms, unit of measurement) or 162 lbs. (pounds, unit of measurement).

A review of Patient 208's Nutrition Evaluation Notes, dated 4/19/23, indicated nutrition assessment was done by the Registered Dietitian (RD) for an order for a three-day calorie count. Patient 208's nutrition assessment estimated indicated Patient 208 required the following nutritional needs:

1. Calories (cal, measurement for unit of energy) 1837 kilocalories (kcal, 1000 calories to 2205 kcal/ day (per 24 hours day).
2. Protein grams (g) 59-74 g protein/day.

A review of Patient 208's Nutrition Evaluation Notes, dated 4/19/23, indicated Patient 208's intake (amount of food eaten) for Day 1 (4/19/23) was Breakfast 0 % (percentage from 0 % to 100 %, indicate intake), Lunch 5%, and no percentage of food documented for dinner. Patient 208's totaling average daily intake was at 2% .

A review of Patient 208's Nutritional Assessment done by RD, dated 4/19/23, indicated Recommend Oral nutrition supplement (Ensure Enlive one can three times a day). The note had no calorie count for Patient 208.

During an observation of the tray line service for lunch on 4/26/23, at 12:00 p.m., Dietary Aide (DA1) was preparing patients trays adding dessert and also adding nutrition supplements as ordered by physician (such as Nepro carb steady [nutritional shake for patient with kidney failure, Ensure [nutritional shake for meal supplement, Glucerna [nutritional shake for meal supplement for patient with high blood sugar] and Juven Nutrition powder [nutritional powder to promote wound healing).

A review of Active Diet order for Patient 208, dated 4/26/23, indicated Patient 208 had an order for oral nutrition supplement (Ensure Enlive, a food supplement designed to help rebuild strength and energy) three times (TID) per day.

During an interview with DA 1 and concurrent review of the orders on 4/26/23, at 12:30 p.m., DA 1 stated she was responsible to add oral nutrition supplements to patients trays during breakfast, lunch, and dinner per physician diet orders. DA 1 stated Patient 208 diet has changed to tube feeding but oral nutrition supplement order has not been discontinued. DA 1 stated the nurses should have discontinued old order.

A review of Patient 208's medical record, on 4/26/23, at 2:50p.m., indicated Patient 208 was admitted to the hospital, on 4/18/23, with diagnoses including failure to thrive syndrome (when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal sometimes has dehydration and depressive symptoms and low immune function) and leukocytosis (high white blood cell count, cells that helps fight off infection or inflammation).

b. A review of Patient 208's nutrition evaluation notes, dated 4/20/23, indicated calorie count for Day 2 (4/20/23), Patient 208 had an intake (amount consumed) breakfast 0 % (none). The nutrition evaluation note indicated Patient 208 has an oral nutrition supplement of Ensure Enlive one can TID. The nutrition evaluation note did not indicate the Ensure Enlive one can TID was provided to Patient 208 on 4/20/23. The nutrition evaluation note indicated no calorie count recorded for lunch and dinner.

A review of Patient 208's medical record indicated no nutrition evaluation note documented from 4/22/23 to 4/25/23 (4 days).

c. A review of Patient 208's Electronic medical records (flowsheets, vital signs measurements) dated 4/21/23, indicated a new weight 61.9 kg or 136.4 pounds (25 pounds or 15% weight loss from time of admission.)

A review of patient 208's nutrition evaluation, notes dated 4/21/23, indicated a calorie count for Day 2 (4/21/23), Patient 208 had an intake for breakfast 20 %, lunch 20 %, and dinner 20 %. The nutrition evaluation notes also indicated Patient 208 had, "Inadequate energy and protein intake related to suspected decreased appetite secondary to confusion." The nutrition evaluation note indicated, Patient 208 was not meeting estimated nutritional needs of 1837 to 2205 kcal/day and 59 to 74 g protein/day.
Dietitian recommended Remeron an appetite stimulant. The nutrition evaluation note does not address Patient 208's weight on 4/21/23 (61.9 kg or 136.4 pounds).

A review of patient 208's medical record (Nutrition evaluation notes) indicated no calorie count for Day 3 (4/22/23) as ordered. Patient 208's medical record had no follow up notes to verify a response to the recommendation for Remeron (an appetite stimulant).

A review of patient 208's medical record, dated 4/24/23, indicated a new order for Tube feeding (therapy where a feeding tube supplies nutrients (food) to people who cannot get enough nutrition through eating.) (Glucerna 1.2 cal 50 cubic centimeter (cc, unit of volume measurement/hour (hr.) providing 1440 calories per day meeting only 78% of estimated needs instead of 100%.

A review of nutrition evaluation notes, dated 4/26/23, indicated the RD recommended to increase tube feeding rate to 65 cc/hr. to meet Patient 208's estimated nutritional, and calorie needs of 1837 to 2205 kcal/day and 59 to 74 g protein/day.

During an interview with Clinical Nutrition manager (CNM) and record review of Patient 208's medical record, on 4/26/23, at 3:24 p.m., CNM stated Patient 208 had no calorie count for Day 3 (4/21/23), because Patient 208 was not eating there was nothing to record. CNM also stated the RD should have communication with physician about nutritional recommendations. CNM stated Patient 208's recommendation for Ensure Enlive three times a day was delayed and not implemented. CNM stated the RD's recommendations for Ensure Enlive (Nutrition supplement) three times a day were not communicated to physician. CNM stated Patient 208 had poor intake and was considered at nutrition risk. CNM stated Patient 208's medical record has no documentation that patient was seen by a dietitian over the weekend (4/22/23 to 4/25/23).

During an interview with lead Registered Dietitian (RD 1), on 4/27/23 at 1:30 p.m., RD 1 stated Patient 208 started tube feeding on 4/24/23. RD 1 stated RD 1 had seen Patient 208, on 4/26/23. RD 1 stated recommending an increase of Patient 208's tube feeding order rate from Glucerna 1.2 cal 50 cc/hr. to 65 cc/hr. to meet patients nutritional and caloric needs of 1837 to 2205 kcal/day.

A review of Facility B's policy and procedure, titled "Initial screening, prioritization and assessment," revised date 2/23, indicated, "When recommendations are made which require a physician order, the Dietitian will follow up within three days to verify a response to the recommendation." The policy and procedure also indicated a dietitian to see patient by the next day when there was a new tube feeding order.

Based on observation, interview, and record review, the facility (Facility A and Facility B) failed to ensure that the Condition of Participation for Physical Environment was met as evidence by:

1. Failure for Facility A and Facility B to maintain hot water temperature used by patients and staffs between 105 degrees Fahrenheit [F, unit of measurement for temperature] to 120 degrees F according facility's policy and procedure.

a.) Facility A's nurses had no hot water to wash hands to performed hand hygiene for two of two sinks observed in the third floor Critical Care Unit's (CCU, intensive unit where people who have life-threatening injuries and illnesses) Medication Room and the Step-Down Unit (SDU, care units between the level of an intensive care unit and the normal ward) North Nursing Station sink. (Cross refer A - 0701).

b.) Facility B's two of two water boilers (a device which burns gas, oil, electricity, or coal in order to provide hot water) that supplies hot water for patient used such as handwashing and bathing were functioning and two of two thermostatic mixing valves (a thermostatic mixing valve is a device that mixes hot water with cold water to provide a safe, accurate, and constant flow of temperature-controlled domestic water) were in working order. (Cross refer A - 0701).

2. Failure to keep Facility A's equipment (such as sinks and showers) maintained and functioning (operable, able to be used) used by patient of one (1) of one sink at the Sixth Floor Behavior Health Unit (BHU) Unit D's Day Room bathroom sink and the four out of five shared patient showers (Shower 1, Shower 2, Shower 3, and Shower 5) on the Sixth floor BHU Unit. (Cross refer A - 0724).

The cumulative effect of these systemic problems resulted in the Facility A and Facility B inability to ensure the Condition of Participation for Physical Environment was met.

Based on observation, interview, and document review, the facility failed to maintain hot water temperature used by patients and staffs, between 105 degrees Fahrenheit [F, unit of measurement for temperature] to 120 degrees F according hospital policy and procedure for two of three facilities surveyed from 4/25/23 to 4/28/23 (Facility A and Facility B).

Facility A failed to ensure nurses had hot water to wash hands in two of two sinks observed used by nurses had third floor Critical Care Unit's (CCU, intensive unit where people who have life-threatening injuries and illnesses) Medication Room and the Step-Down Unit (SDU, care units between the level of an intensive care unit and the normal ward) North Nursing Station sink.

This deficient practice had the potential to limit proper hand hygiene and suitable disinfection procedures exposing patients and staff to an unsafe environment that could spread infection and increase the likelihood cross contamination.

Facility B failed to:

1. Ensure facility's two of two water boilers (a device which burns gas, oil, electricity, or coal in order to provide hot water) that supplies hot water for patient used such as handwashing and bathing were functioning.

2. Ensure two of two thermostatic mixing valves (a thermostatic mixing valve is a device that mixes hot water with cold water to provide a safe, accurate, and constant flow of temperature-controlled domestic water) were in working order.

The deficient practice resulted to fluctuating hot water temperature (either below or above hospital's hot water temperature range of 105 degrees F to 120 degrees F). The deficient practice had the potential to cause burn to patients and staffs, when the hot water was too hot and not able to provide warm water for handwashing when the hot water was not below 105 degrees F.

Findings:

Facility A:

1. On 4/25/23 at 4:15 p.m., during a concurrent observation of the third floor Critical Care Unit's (CCU, intensive unit where people who have life-threatening injuries and illnesses) Medication Room and interview with the Plant Operations Director (POD), POD observed activating the sink sensor in the Critical Care Unit (CCU) and POD stated the water felt cold after allowing the water to run for several minutes. The POD used the facility thermometer and stated the water temperature in the CCU Medication Room sink was less than 90 degrees F (below hospital's hot water temperature range was for 105 degrees F to 120 degrees F). POD stated the how water temperature was not at the appropriate temperature range. POD stated Facility A will fix the water mixing valve (valve used to control the temperature of the water before it goes to the sinks and showers) and provide proof when the water temperature is in appropriate range.

On 4/26/23 at 2:31 p.m., during an interview, the POD stated the following reasons for why the hot water not reaching or maintaining the appropriate temperatures:

a. The cold water may be plumbed (straight) into the hot line (hot water pipes), and Facility A was trying to find the areas that have this problem.

b. The water may not be circulating fast enough to maintain a steady temperature.

c. There may be areas where there was no recirculating water (hot water to fixtures such as sink).

On 4/26/23 at 2:54 p.m., during an interview, the POD stated the CCU Medication Room hand washing sink required a water shut down. The POD stated the CCU Medication Room sink has cold water and no hot water at this time.

On 4/27/23 at 11:18 a.m., during a concurrent observation the Step-Down Unit (SDU, care units between the level of an intensive care unit and the normal ward) North Nursing Station sink and interview with the Director of Critical Care (DCCU-100) DCCU observed and measured the hot water temperature with a digital handheld thermometer at the SDU North Nursing Station sink. The DCCU thermometer reading revealed the water temperature at 63.5 degrees F (below hospital's hot water temperature range was for 105 degrees F to 120 degrees F). The DCCU also stated the water temperature was below normal range.

On 4/27/23, during an interview at 11:19 a.m., The SDU Registered Nurse (RN-114), stated she uses the SDU North Nursing Station sink to wash her hands. RN 114 stated the water felt a little chilly and had remained at the same temperature during handwashing.

On 4/27/23, during an observation and interview at 11:21 a.m., the Infection Control Registered Nurse (RN-108) was observed looking down at the two-foot pedals under the SDU North Nursing Station sink. The two-foot pedals observed marked with a letter "C" (indicating cold water). RN-108 stated both foot pedals indicated cold water.

On 4/27/23 at 11:58 a.m., during a concurrent observation Step-Down Unit (SDU) North Nursing Station sink and interview with the Chief Operating Officer (COO-100), POD-100, and Registered Nurse (RN-114). The water temperature at the Step-Down Unit (SDU) North Nursing Station sink was measured at maximum of 89 degrees F after being allowed to continuously run for approximately 5 minutes using the Surveyor's digital thermometer to take readings over time period. RN-114 stated the water at the sink was always continuously providing room temperature to cooler water.

A review of Facility A's policy and procedure titled, "Hand Hygiene," dated 7/2022, indicated, "Hands visibly dirty or contaminated ...should be washed with ... microbial (bacteria that cause disease or infection) soap and water." The policy and procedure for hand washing included for staff to, "Wet hands first with warm water ...rub hands together vigorously for twenty (20) seconds, covering all surfaces of the hands and fingers."

A review of the Facility A's policy and procedure titled, "Control Domestic Hot Water Temperature," dated 9/2022, indicated, the temperature and pressure of hot water delivered to plumbing fixtures were at a range of 105 degrees F minimum to 120 degrees F maximum." The policy and procedure also indicated, "Hot water distribution systems provide hot water within the required temperature ranges at each fixture at all times."

Facility B:

1. A review of Facility B's repair work provided by Facility B for the facility's Boiler 1 and Boiler 2 between the facility's contracted plumber and Director of Construction and Design indicated the following the events:

a. On 04/18/23, plumber received call from the hospital requesting service on the hospital boilers (Boiler 1 and Boiler 2) that were working on/off intermittently.

b. On 04/19/23, the plumber arrived on site, discovering Boiler 2 was not working, and Boiler 1 was in use but not able to provide adequate hot water temperature. That there were multiple parts missing from Boiler 2, and Boiler 1 had a leak through the tube bundles (tube bundles were the heating elements that exchange and transfer heat into the water that is then used for domestic hot water requirements).

c. On 04/20/23, during repairs, it [boilers] became apparent replacement parts were needed, and help removing the tube bundles from Boiler 2 which were in good condition and replacing them with the tube bundles that were leaking from Boiler 1. After completing repairs, Boiler 1 was operational again providing hot water to the entire hospital. To perform the repair, the necessary components were removed Boiler 2, which was out of service due to unavailability of required parts.

d. On 04/24/23, the plumber was contacted again by the hospital urgently requesting service on boiler 2.

e. On 04/25/23, the plumber arrived to inspect Boiler 2 and gather a list of the required parts for its (Boiler 2) repair. The items identified for the repair for Boiler 2 were gas solenoid valve (used to control the flow of a gas in a boiler), ignition transformer (used to ignite a mixture of gas and air by delivering a high-energy spark), contactor (electrical switch used to turn on and off the electricity to the hot water unit unit), recirculating pump (pump used to circulate hot water so that it is available to all sinks and showers), relay (a relay on a boiler is the part of the boiler system which triggers the boiler to release heat when the thermostat calls for it), limit switches (a switch that operates as an automatic control to prevent a mechanism or process from going beyond a prescribed limit), and hot water bundle (a heating component for hot water heaters) .

On 4/25/23 at 2:25 p.m., during an observation with Director of Plant Operation (DPO) and the National Vice President of Facilities Development (NVPFD) at Facility B, one of two boilers was observed disassembled (boiler not intact and non-functioning). Boiler 1 was missing its tube bundle cover (the cover that goes over the bundle), and recirculating pump.

On 04/25/23, at 2:25 p.m., during an interview, DPO and NVPFD stated and identified the disassembled boiler on the left was Boiler 1, and the assembled (intact and functioning) boiler on the right was Boiler 2. Both (DPO and NVPFD stated the missing parts from Boiler 1 were taken off to repair Boiler 2, so that the hospital would have one good working boiler.

On 04/25/23, between 2:50 p.m. and 3:10 p.m., during an observation, the facility's Maintenance Engineer took temperature of hot water temperature with a digital thermometer at the following locations:

a. The 6th floor pharmacy hand washing sink water temperature measured at 137 degrees F (above hospital's hot water temperature range was for 105 degrees F to 120 degrees F).


b. The 6th floor common area (used by staff) men's restroom hand washing sink water temperature measured at 79 degrees F (below hospital's hot water temperature range was for 105 degrees F to 120 degrees F).


c. The 6th floor common area (used by staff) women's restroom hand washing sink water temperature measured at 122 degrees F (above hospital's hot water temperature range was for 105 degrees F to 120 degrees F).

On 4/25/23 at 3:10 p.m. to 3:42 p.m. during observation with Assistant Chief Nursing Officer (ACNO-200) and Infection Control Coordinator (ICC-200), the following water temperatures were measured using the Surveyor's thermometer at the following sinks on the third floor:

a. The clean utility room sink water temperature measured at 97 degrees F (below hospital's hot water temperature range was for 105 degrees F to 120 degrees F).

b. The clean Utility Room sink (across from Med Room) water temperature measured at 89 degrees F (below hospital's hot water temperature range was for 105 degrees F to 120 degrees F).

c. The hand washing sink in Intensive Care Unit (ICU) water temperature measured at 85 degrees F (below hospital's hot water temperature range was for 105 degrees F to 120 degrees F).

d. The hand washing sink in Critical Care Unit (CCU) water temperature measured at 66 degrees F (below hospital's hot water temperature range was for 105 degrees F to 120 degrees F).

e. The bathroom sink in Patient Room 303 water temperature measured at 86 degrees F (below hospital's hot water temperature range was for 105 degrees F to 120 degrees F).

On 04/25/23, during an interview at 3:34 p.m., the Maintenance Engineer stated that Boiler 2 tripped (shut off). The Maintenance Engineer stated when the boiler trips, it (the boiler) sets off all the pumps because it's a safety feature so that the hot water would go off. The Maintenance Engineer also stated he does not know why the Boiler 2 tripped. The Maintenance Engineer stated that the boiler limit switch for Boiler 2 had a high limit for 200 degrees F. The Maintenance Engineer stated Boiler 2 had a low limit switch setting at 150 to 160 degrees F.

On 4/25/23 at between 3:58 p.m. to 4:05 p.m., during observation with Director of Design and Construction (DDC-200), Director of Quality of Risk (DQR-200), and Environmental Health Specialist (EHS-200), the Operation Room Break Room hand washing sink used by staff in the basement level of Facility B was observed that the hot water fluctuated several times between 105 degrees F to 87 degrees F.

On 04/25/23, during an interview at 4:30 p.m., the Maintenance Engineer stated the safety setting (high limit) for Boiler 2 should have been set at 180 degrees F and not set at 200 degrees F.

On 04/26/23, between 11:05 a.m. and 12:30 p.m., the Maintenance Engineer measure hot water temperature with digital thermometer at the following locations:

a. Patient Room 308 hand washing sink water temperature measured at 122 degrees F (above hospital's hot water temperature range was for 105 degrees F to 120 degrees F).

b. 4th floor nurses station hand washing sink water temperature measured at 123 degrees F (above hospital's hot water temperature range was for 105 degrees F to 120 degrees F).

c. Patient Room 404 hand washing sink water temperature measured at 124 degrees F (above hospital's hot water temperature range was for 105 degrees F to 120 degrees F).

d. Patient Room 411 hand washing sink water temperature measured at 124 degrees F (above hospital's hot water temperature range was for 105 degrees F to 120 degrees F).

e. Patient Room 507 hand washing sink water temperature measured at 123 degrees F (above hospital's hot water temperature range was for 105 degrees F to 120 degrees F).

On 04/28/23 at 11:20 a.m., during an interview, the Director of Plant Operations stated the hospital had been working with Boiler 2 for nine days, since 04/19/23. The DPO stated prior to 04/19/23, the hospital was using Boiler 1. The DPO stated Boiler 1 provided hot water at a temperature of 105 degrees F to 120 degrees F intermittently and not consistently.

On 04/28/23, between 12:00 p.m. and 12:40 p.m., the Maintenance Engineer measured hot water temperature with a digital thermometer at the following locations:

a. The 3rd floor Intensive Care Unit (ICU) Non-touch handwashing sink water temperature measured at 95.5 degrees F (below hospital's hot water temperature range was for 105 degrees F to 120 degrees F).

b. The 6th floor pharmacy hand washing sink water temperature measured at 121 degrees F (above hospital's hot water temperature range was for 105 degrees F to 120 degrees F).

On 04/28/23, during an interview at 3:20 p.m., the Director of Plant Operations stated the plumber was at the Facility B (no date given) to extract the tube bundle from the boiler room to repair or rebuild the tube bundle from Boiler 1. The DPO stated the plumber would be back on Monday (5/1/23) with all the parts necessary to repair Boiler 1 and have both boiler (Boiler 1 and Boiler 2) in operating condition.

A review of the Facility B's policy and procedure titled, "Control Domestic Hot Water Temperature," approved date 9/22, indicated, "It is the policy of the Plant Operations Department that temperature controls or control valves shall be provided to automatically regulate the temperature and pressure of hot water delivered to plumbing fixtures used by patients with a range of 105 degrees F to 120 degrees F Maximum." The policy and procedure also indicated, "Hot water distribution system provide hot water within the required temperature ranges at each fixture at all times."

2. On 04/26/23 at 3 p.m., during an interview, Facility B's contracted plumber stated the mixing valves were a little hot, and they (mixing valves) needed to be set at around 120 degrees F, maintaining the water temperature to be at 110 degrees F to 120 degrees F, but instead were set at about 132 degrees F. needed to be set at around 120 degrees F, maintaining the water temperature to be at 110 degrees F to 120 degrees F, but instead were set at about 132 degrees F.

On 04/26/23 at 4:20 p.m., during an observation with Facility B's contracted plumber and National VP of Facilities Development (NVFD) and concurrent interview, the two mixing valves located in the hot water holding tank room that piped in the domestic water system between the hot water holding tank and two aqua stats (device that senses and controls water temperature and a switch that turns the boiler on and off to maintain the right hot water temperature) were observed. Facility B's contracted plumber stated he was not able to adjust the mixing valves. Facility B's contracted plumber stated would adjust the aqua stats to 120 degrees F so that the hot water temperature would go above 120 degrees F and would be allowed to go past the aqua stats to the domestic water system.

On 04/28/23, during an interview at 10:20 a.m., the Director of Construction and Design stated Facility B's contracted plumber would be arriving at the hospital at noon (12 p.m.) to replace the mixing valves.

On 04/28/23, during an interview at 3:20 p.m., the Director of Plant Operations stated the plumber arrived at the hospital and replaced the two mixing valves in the hot water holding tank room with two new mixing valves.

On 4/25/23 at 3:10 p.m. to 3:42 p.m. during observation in the presence of the Assistant Chief Nursing Officer (ACNO-200) and Infection Control Coordinator (ICC-200), the following water temperatures were measured using the surveyor's digital thermometer at the following sinks on the third floor:

a. The clean utility room sink (located in the middle of the third floor) water temperature measured at 97 degrees F (below hospital's hot water temperature range was for 105 degrees F to 120 degrees F).

b. The clean utility room sink (located across the third-floor medication room) water temperature measured at 89 degrees F (below hospital's hot water temperature range was for 105 degrees F to 120 degrees F).

c. The hand washing sink in Intensive Care Unit (ICU) water temperature measured at 85 degrees F (below hospital's hot water temperature range was for 105 degrees F to 120 degrees F).

d. The hand washing sink in Critical Care Unit (CCU) water temperature measured at 66 degrees F (below hospital's hot water temperature range was for 105 degrees F to 120 degrees F).

e. The bathroom sink in Patient Room 303 water temperature measured at 86 degrees F (below hospital's hot water temperature range was for 105 degrees F to 120 degrees F).

On 4/25/23 at between 3:58 p.m. to 4:05 p.m., during observation with Director of Design and Construction (DDC-200), Director of Quality of Risk (DQR-200), and Environmental Health Specialist (EHS-200), the Operation Room Break Room hand washing sink used by staff in the basement level of Facility B was observed that the hot water fluctuated several times between 105 degrees F to 87 degrees F.

A review of Facility B's policy and procedure titled, "Safety and Equipment Maintenance," revised date 1/2018, indicated the maintenance of the physical plan and all equipment was the responsibility of the Director with the Maintenance Department.

Based on observation, interviews, and record review, the facility failed to keep facilities equipment (such as sinks and showers) maintained and functioning (operable, able to be used) for patient use for one of three surveyed facilities (Facility A) from 4/25/23 to 4/28/23. Facility A failed to:

1. Ensure one (1) of one sink the Sixth Floor Behavior Health Unit (BHU) Unit D's Day Room bathroom sink the patient use for handwashing wash working for patient to use for handwashing.

2. Ensure four (4) out of five (5) shared patient showers (Shower 1, Shower 2, and Shower 3, and Shower 5) on the Sixth floor BHU Unit were not operable or not in service.

This deficient practice resulted to patients not able to wash hands in the Sixth Floor BHU Unit D's bathroom sink, and patients not able to use the four inoperable shared patient showers since 10/2022 (about 6 months).

Findings:

1. On 4/26/23 at 11:53 a.m., during a concurrent observation of the Sixth Floor BHU Unit D's Day Room bathroom with Behavioral Health Director (BHD - 101) and interview, the Sixth Floor BHU Unit D's Day Room bathroom was observed and had a sink the patient use for handwashing. The Day Room's bathroom sink was observed with no water coming out of the faucet when a hand was placed on the faucet sensor for water to come out. BHD-101 stated the sink in the Day Room's bathroom does not work due to the battery on the sensor went out. BHD-101 stated she did not know how long the Day Room bathroom sink had not been working, and the facility does not keep a log to verify if the Day Room bathroom sink was working or not.

On 4/26/23 at 11:55 a.m., during an interview, the Plant Operations Director (POD - 100) stated the Sixth Floor BHU Unit D's Day Room bathroom sink was not working and the facility will have to put in a work order. POD -100 stated there was an engineer assigned to the different floors and units that do daily rounds. POD - 100 stated he does not know how long the BHU Unit D's Day Room's bathroom sink has not been working and did not remember seeing a work order indicating that the sink was not working.

On 4/27/23, during an observation conducted at 10:01 a.m., with Plant Operations POD - 100 and Chief Operating Officer (COO-100) present, it was observed that the Sixth Floor BHU Unit D's Day Room bathroom sink was inoperable.

2. On 4/27/23 at 9:56 a.m., during a concurrent observation of the five individual showers inside of individual rooms separated by a wall used by all patients on the Sixth Floor BHU Unit for showering and interview with the POD - 100 and COO-100, the shared patient showers were observed, and four out of five shared patient showers (Shower 1, Shower 2, and Shower 3, and Shower 5) were not operable or not in service. POD - 100 stated two of the shared patient showers (Shower 1 and Shower 3) were not able to be used by patients on this floor, because when the shower was used the water pooled on the floor and ends up flooding outside of the shower rooms into the hallway.

On 4/27/23 at 9:56 a.m., during an interview, POD - 100 stated when the water pooled, the pooled water also leak onto the Fifth Floor below when the showers were in use. POD - 100 stated Facility A does not have a permit filed to repair the two not operable shared patient shower. POD - 100 stated the facility had not secured a contract with a vendor to complete the work. The Shower 2 and Shower 5 were observed inoperable due to a lack of handle to turn on and off the flow of water on the showers. POD -100 stated the shared patient showers had been inoperable or not in use, since 10/2022.

A review of Facility A's policy and procedure titled, "Plan Operations Corrective Maintenance," dated 9/2022, indicated, "The Plant Operations Department shall develop, implement, manage a corrective maintenance program. Requestors shall be kept informed about all repair status." The policy and procedure indicated, "All employees of the Medical Center shall report any repair requests for non-medical equipment failures to the Plant Operations Engineering."

Based on observation, interview, and record review, the facility failed to ensure that the Condition of Participation for Infection Prevent and Control and Antibiotic Stewardship Programs were followed for one (1) of the three hospitals surveyed (Facility B) from 4/25/23 to 4/28/23. Facility B's Food and Nutrition services failed to:

1. Ensure food items (desserts, milk, and juice for patients on regular or mechanical soft diet) were dated and labeled in the facility's main kitchen reach in refrigerator, the freezer located in the facility's main kitchen, and in refrigerator on the 4th floor nursing station. (Refer to A - 0749).

2. Ensure food scooper were stored properly inside facility's bulk food containers located in the facility's main kitchen. (Refer to A - 0749)

3. Ensure the facility's refrigerators and freezers maintained safe food storage temperatures located in the facility's main kitchen. (Refer to A - 0749).

4. Ensure food seasonings and cooking condiments were stored in a clean environment located in the facility's main kitchen.. (Refer to A - 0749).

5. Ensure routine cleaning of the ice machine located in the facility's main kitchen. (Refer to A - 0750).

6. Implement and maintain an infection control and surveillance program in the facility's main kitchen (Refer to A - 0750).

The cumulative effect of these deficient practices had the potential to result in in food borne illness in patients, staffs, and visitors who consume the food prepared and or stored at the Facility B's main kitchen and in refrigerator on the 4th floor nursing.

Based on observations, interviews and record reviews, the Food and Nutrition services failed to ensure infection control practices were followed in one (1) of the three hospitals surveyed (Facility B) from 4/25/23 to 4/28/23. Facility B's Food and Nutrition services failed to:

1. Properly date and label several food items (desserts, milk, and juice for patients on regular or mechanical soft diet) were not dated and labeled in the facility's reach in refrigerator and the freezer located in the facility's main kitchen. Lemon/lime previously prepared juice was labeled with incorrect dates of 4/17/23(open/prepared date) to 6/16/23 (discard date) exceeding storage period for juice. A patient's food (Patient 204 and Patient 209) in a closed container from outside in to go boxes was stored in the refrigerator in nursing station nourishment room (4th floor) had no date.

2. Appropriately store scoops were stored inside facility's bulk rice container and flour container. The scoops were in contact with the food (rice and flour) located the the facility's main kitchen.

3. Maintain A refrigerator in nursing station nourishment room (5th floor) did not maintain safe food storage temperatures of 41 degrees Fahrenheit [F, unit of temperature measurement] or below) for Time and Temperature Control for Safety (TCS) foods (foods susceptible for bacterial growth that can result in food borne illness when not safely stored and prepared) in a refrigerator in the nursing station nourishment room (5th floor). A walk-in freezer in the facility's main kitchen did not maintain a safe food storage temperature of 0 degrees F for foods stored in freezer. Ready-made (ready to eat) pureed food and bread sticks were thawed and felt soft to touch (Frozen food were maintained to be hard to touch) located the the facility's main kitchen. .

4. Clean the shelf that held the seasonings and cooking condiments had dust. The bottles of soy sauce, sesame oil on the shelf were sticky and not clean. The bottle of balsamic vinegar on a corner shelf had drippings of balsamic vinegar around the bottle. Gnats (small flies) were flying around the bottle and hiding behind the balsamic vinegar bottle in the corner of the shelf located the the facility's main kitchen.

The deficient practices resulted to small flies (gnats) in the kitchen around the kitchens seasoning and condiments. The deficient practices had the potential to result in food borne illness in patients, staffs, and visitors who consume the food prepared and or stored at the stored at the kitchen and in refrigerator on the 4th floor nursing and the Facility B's main kitchen.

Findings:

1. During a tour of the kitchen, on 4/25/23 at 1:40 p.m. with the Director of Food and Nutrition Service (DFNS), the following were observed inside the facility's reach in refrigerator:
a. An open container of non-dairy milk with no discard date.
b. Brownies in individual small cups for dessert had no dates.
c. Five (5) individual containers of cut cake for mechanical soft diet had no label.
d. 10 small containers of regular sliced cake with no label.
e. Four (4) plastic cups filed with lemon/lime juice with preparation date of 4/17/23 and discard date of 6/16/23 exceeding storage period (stored for 6 days) for prepared juice per facility policy.

During a concurrent observation and interview with DFNS, on 4/25/23 at 1:40 p.m., the DFNS stated that facility provides label machine that was programmed to print labels with open and discard dates. The DFNS stated the cake was prepared in advance and cut in order of prescribed diet texture and type. The DFNS stated the cakes should be labeled with preparation date and identify type of diet. The DFNS stated some patients request lemon juice to drink with their meal, and the DFNS stated the lemon juice were previously prepared (prepared date 4/17/23). The DFNS stated the poured juice (lemon juice) has a shelf life of 6 days. The DFNS stated the wrong label was printed (discard date of 6/16/23) on the lemon juice and discarded the four cups with lemon juice.

During an observation of the nursing station nourishment room on the 4th floor, on 4/26/23 at 10:15 a.m. with Registered Nurse 206 (RN 206), food brought from outside for patients in to go containers was stored inside the nourishment refrigerator with no date. The plastic bags had labels with patients' names and admission date, but no date to indicate when food was brought in. One bag (Patient 204) with admission date 4/17/2023, and the second bag (Patient 209) had a patient name and 4/21/2023 admission date.

During an interview, on 4/26/23 at 10:15 a.m., RN 206 stated the food was brought in for the two patients but doesn't know when. RN 206 stated there was no date to tell when the food was placed in the refrigerator. RN 206 stated the dietary staff were responsible to check the temperature of the refrigerators and check snack inventory. RN 206 stated nurses were responsible to make sure patient food from outside was dated and labeled with date of discard. RN 206 discarded the two patients' food that was brought from outside. RN 206 stated the food storage policy in the nourishment refrigerators was the same as in the kitchen.

A review of Facility B's policy and procedure titled, "Refrigerated storage life of foods," dated 1/2023, indicated, "individual juice that is open is stored for 6 days."

A review of hospital policy and procedure titled, "Food and Supply Storage," revised date 1/2023, indicated, "Foods past the ... use-by .... sell-by ...,..best-by..., or ..enjoy by ... date should be discarded." Food should have "Cover, label and date unused portions and open packages."

2. During an observation in the kitchen, on 4/25/23 at 3:00 p.m. with the DFNS, there was a bulk dry food storage bin stored under the counter in the food preparation area. The bin contained rice and the scoop was stored inside the bin and the handle of the scoop was touching the rice. There was another bulk dry food storage bin that contained flour, a scoop was stored inside on the bin. The scoop handle was touching the flour.

During an interview, on 4/25/23 at 3:00 p.m., the DFNS stated there were scoop holder inside the bins (rice and flour bins). DFNS stated it (scoop holder) must have fallen on the food. The DFNS stated the rice was filled all the way to the top and that caused the scoop to fall. DFNS said the scoop handle should not touch food to prevent cross contamination.

A review of hospital policy and procedure titled, "Food and Supply Storage", revised date 1/2023, indicated, "Hang scoop. Scoops may be stored in bins on a scoop holder. The food level must be no closer than one inch below the handle of the scoop."

A review of the FDA Food Code 2022 code 3-304.12, "In-Use Utensils, Between-Use Storage," indicated, during pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored, in food that is not time/temperature control for safety food with their handles above the top of the food within containers or equipment that can be closed, such as bins of sugar, flour, or cinnamon.

3. During an observation of the nursing station nourishment room on the 5th floor on 4/26/23, at 10:00 a.m., the temperature of the below the counter refrigerator was at 45 degrees F. The refrigerator observed with juices and milk stored for patients. DFNS did a temperature check of the milk carton stored inside the refrigerator using facility thermometer and the facility thermometer registered a temperature of 43.5 degrees F (normal temperature range for refrigerator storage was to be maintained at 41 degrees F or below).

During a concurrent observation and interview, on 4/26/23, at 10:00 a.m., DFNS stated kitchen staff records the refrigerator temperatures located inside the nurses' station and adds or restocks those refrigerators with snacks for patients. DFNS looked at the temperature dial inside the refrigerator and stated the temperature of the refrigerator had been set high at 46 degrees F (normal temperature range for refrigerator storage was to be maintained at 41 degrees F or below). DFNS observed turn the temperature dial inside the refrigerator and set the thermostat of the refrigerator at 36 degrees F. DFNS stated the milk was to be discarded.

A review of hospital policy and procedure, titled "Cold Storage Temperatures" dated 1/2023, indicated, "Temperatures of food storage areas and cold food vendors are monitored and action to taken to maintain temperatures within ranges recommended by licensing and surveying agencies. Refrigerated storage maintain at 41 degrees F or below ...Take temperatures of potentially hazardous foods to determine if food has exceeded 41 degrees F, if there is reason to suspect that potentially hazardous food has exceeded 41 degrees F for more than 2 hours, discard the food."

A review of hospital policy and procedure titled "Food and Supply Storage" dated 1/2023, indicated, "Milk will be refrigerated immediately upon receipt. As with all refrigerated storage, temperature must be maintained at 41 degrees or below."

During an observation in the kitchen, on 4/26/23, at 11:15 a.m., the walk-in freezer was at 10 degrees F. A box of ready-made pureed sausage observed and was soft to touch. Bread sticks observed and were soft to touch, and a frozen dough observed and was soft to touch.

During a concurrent observation and interview with Regional Director of Operations (RDO) on 4/26/23, at 11:15 a.m., she stated that the freezer temperature was noted out of range yesterday and food is being checked every hour and as of last report today it was solid. RDO checked the food that was soft to touch and stated she will remove the pureed sausage and bread sticks and store them in the refrigerator to be used. She said she will check all the food in the freezer and any item that is not frozen solid will be removed. RDO also said that engineers worked on the freezer yesterday morning and by evening the temperature was at below zero, but unfortunately it is out of range again today.

A review of the walk-in freezer temperature log for the month of 4/2023 indicated on 4/25/23 the freezer temperature at 5:00 a.m. was at 20 degrees F and on 4/26/23 the freezer temperature at 5:00 a.m. was at 10 degrees F.

A review of hospital policy and procedure, titled "Food and Supply Storage" dated 1/2023, indicated, "Frozen foods must be held solidly frozen so that they are hard to the touch."

4. During an observation in the kitchen with the DFNS, on 4/25/23, at 1:40 p.m., there were bottles of condiments such as soy sauce, balsamic vinegar and sesame oil stored on the shelf located above the produce wash and preparation sink. The bottle of sesame oil and the bottle of balsamic vinegar were sticky and dirty with residue of the contents. Gnats (small flies) observed around the bottles and hiding behind the large plastic container of the balsamic vinegar.

During an interview, on 4/25/23, at 1:40 p.m., DFNS stated that we should clean the bottles to prevent the flies around the vinegar. He then said he will remove the balsamic vinegar from the shelf and contact pest control.

A review of facility's Pest Control Report, dated 4/25/23 time at 7:01 a.m. with time out 7:38 a.m., indicated no pest activity. The pest control report did not indicate if kitchen was inspected.

A review of facility's policy and procedure, titled "Pest Control," revised date 1/2023, indicated, "The Food and Nutrition Services Department shall be free of all rodents and insects."

Based on observation, interview, and record review the facility failed to follow routine surveillance to maintain a clean and sanitary environment in the Food and Nutrition Services area for one of three surveyed facilities (Facility B) from 4/25/23 to 4/28/23. Facility B failed to:

1. Conduct April monthly cleaning for the ice machine baffle (keeps ice from falling out of the bin when the ice machine door was opened) and ice machine bin.

2. Implement Kitchen Routine infection control and audit action, dated 2/24/23, and correct food inspection report, date 2/24/23, and conduct daily kitchen cleaning checklist from 2/27/2023 to 4/9/2023 (40 days).

The deficient practices resulted to greyish slimy substance and two rusty screws on the ice machine baffle, and rust sliding down on the ice machine bin. This had the potential to result in food borne illness in patients, staffs, and visitors who consume the food prepared by Facility B's kitchen.

Findings:

1. During an observation with the Director of Food and Nutrition Service (DFNS), on 4/25/23, at 3:15 p.m., the facility ice machine stored in the kitchen was inspected. A clean paper towel swipe of the ice storage bin baffle produced greyish slimy substance. The baffle observed and attached inside the ice machine bin with greyish slimy substance. The screws had a rusty orange color touching ice in the storage bin and the condensation on the screws along with the rust was sliding down on ice in the bin. The air filters of the ice machine were not clean and had dust inside it (air filters).

During an interview with DFNS, on 4/25/23, at 3:15 p.m., DFNS stated the ice machine internal compartments including the baffle and the air filter were cleaned by engineering department. DFNS said the outside of the ice machine was cleaned by environmental staff and the kitchen staff monthly.

During concurrent interview with DFNS and record review of the ice machine cleaning log, on 4/25/23, at 3:15 p.m., indicated monthly exterior cleaning was not done for April, bimonthly air filter cleaning was not done for April, and monthly water filter was not done for April. DFNS stated he will inform engineering department that the ice machine was not cleaned per policy.

During an interview with Director of Engineering (DE), 4/25/23, at 4:00 p.m. DE stated kitchen staff responsible to clean ice machine bin.

A review of hospital policy and procedure, titled "Cleaning and maintenance of ice machines" revised date 4/2022, indicated, "Dietary is responsible for internals bins, and outside of machine. Environmental services are responsible for the external surface cleaning of the machines, and engineering is responsible for the maintenance, quality checks, and as needed repairs of both the internal and external components of the ice machines."

2. A review of Facility B's Kitchen Routine infection control and food safety audit, dated 2/24/23, indicated there were signs of discoloration on walls, floors and deep cleaning was scheduled as an action plan.

A review of Los Angeles County, "Retail food official inspection report," dated 2/24/23 indicated, "Observed broken, missing tiles, and grout on wall under mechanical ware wash machine. Observed debris accumulation on floor under 3 doors reach in cooler."

A review of the Daily kitchen cleaning checklist, dated 2/27/2023 to 4/9/2023, indicated mopping and scrubbing floors was not scheduled. There was no cleaning checklist available for dates after 4/9/2023.

A review of the QAPI (QAPI- Quality Assurance and Performance Improvement-proactive approach that continuously studies processes with the goal to prevent or decrease the likelihood of problems in care delivery) reports for the kitchen, dated 1/2023 to 3/2023, indicated performance improvement measures were monitored for the temperature of the kitchen environment and timely equipment repairs. There were no performance improvement activities that addressed the deficient and non-compliant practices in the kitchen related to infection control.

During a tour of the kitchen with DFNS, on 4/25/23, at 3:00 p.m., the wall tiles or backsplash behind the stove and ice machine had brown color splashes and stains. The tiles on the floor under and around the stove had sticky stains. There was a thick layer of dust under the counter where food was served in cafeteria. There was also trash in the corners under the food service counter. The food service counter that had thick layer of dust. Paper towels was observed in the corners in between the cafeteria and kitchen food preparation area.

During an interview, on 4/25/23, at 3:00 p.m., DFNS stated the kitchen floors are moped everyday by kitchen staff. DFNS stated the cafeteria side was cleaned by environmental staff and they (environment staff) were responsible for cleaning under the food service counter. DFNS stated the facility was looking for an outside company that can provide deep cleaning services.

During an interview with Director of Engineering (DE), 4/25/23, at 4:00 p.m., DE stated the environmental department was responsible to mop floors in the cafeteria. DE stated the dust accumulation and trash under counter not acceptable.

During an interview, on 4/26/23 at 1:30 p.m., DFNS stated sanitation and infection control findings identified on 4/25/23 and 4/26/23 are not part of performance improvement project in the Food and Nutrition Department.

During an interview with Regional Director of Operations (RDO), on 4/28/23 at 11:30 a.m., RDO stated the facility was informed by the LA County Environmental Health Inspector of the cleaning issue in the kitchen during an inspection in February of 2023 that is why the facility has reached out to an outside company to provide deep cleaning services.

A review of Food and Drug Administration (FDA) food code 2022, code 4-601.11 titled, "Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils," undated, indicated, "Nonfood-contact surfaces of equipment shall be kept free on an accumulation of dust, dirt, food residue and other debris." The FDA food code indicate nonfood such as, "CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues. The FDA food code indicated, "The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests."