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Based on observation and interview, it was determined the hospital did not ensure the Director of Food Services was responsible for the daily management of dietary services. Specifically, the Director did not ensure safe practices for food handling and storage.


Findings include:


On 12/13/17, at approximately 9:30 AM, a tour of the kitchen was conducted with an employee who identified herself as the manager on duty. The Director of Food Services later identified her as the Sous Chef. At approximately 10:50 AM, a second tour was conducted with the Director. During both tours, several examples of food safety negligence were observed. Specifically, there was inappropriately stored foods, unlabeled foods, uncovered foods, moldy foods, expired foods, and a floor drain that appeared unsanitary.


1. While touring the dry storage area, surveyors observed the following:

A large package of chocolate chips left open and exposed to air. When the Sous Chef was asked about it, she proceeded to close 2 flaps of the outside box; however the food was still exposed to air.

A plastic bag of dried pasta was observed to have a manufacturers "use by date" of 10/13/17. When the Sous Chef was asked about it, she stated, "it's hard to say when dried stuff will go bad."

Several other dried foods were observed to be opened and not dated including; granola, pasta, Chinese noodles, flour, rice, and bread crumbs.

A 10 pound box of croutons was observed on the bottom shelf, fully open. It was observed to be approximately half empty. There was no evidence of when it had been opened.

A box containing 12 packages of corn tortillas was observed to have a manufacturer's "expiration date" of September 24, 2017. Four other packages were observed to have a manufacturer's "expiration date" of November 12, 2017.


2. While touring the walk-in refrigerator, surveyors observed the following:

Several single serve containers of lime yogurt with manufacturer's "expiration date" of December 12, 2017.

There was an open package of bagels with a manufacturer's "best by date" of November 17, 2017. It had a hand written label that read, "opened 12/3". Half of the bagels were gone. Another package of bagels was observed to have a manufacturer's "best by date" of November 30, 2017.

An open container of sour cream with a manufacturer's "best by date" of November 30, 2017, was observed. It was labeled as being opened 12/3/17. There was a second unopened container of sour cream with the same manufacturer's "best by date".

There was a container of turkey stock observed to have a manufacturer's "expiration date" of September 21, 2016. A container of vegetable stock was observed to have a manufacturer's "expiration date" of October 3, 2017. Both containers were observed to have dark green mold around their dispensing spouts. When the Director was questioned about it, he stated the stocks were seldom used so they had not noticed the expiration dates or mold.

Several packages of various cheeses were observed to be opened but were not dated to identify when they were opened or when to discard them.

Two large metal bins containing fresh chicken breasts were observed. One bin had a sticker with the date 12/11; the second bin was not dated. The Director was asked what the date represented. He was unable to say if it was the opened date or expiration date.

Multiple trays of various, individually plated desserts were observed in three different refrigerators. They were not covered or dated. When the Director was questioned about it, he stated they prepared the desserts each day and planned to use them on that day, so they did not cover or date them. When asked how he would verify they were not from previous days, he stated he could not.


3. While touring the hot food preparation area, surveyors observed the following:

A drain was observed in the floor of the "cook's line", (the area where the cooktops and steam tables were located). The drain was approximately 6 feet long and 1 foot wide. It was observed to contain a great deal of food waste, garbage, a ball point pen, and a sharpie marker.

On 12/13/17 at approximately 2:00 PM, a follow up interview was conducted with the Director. The Director stated that the kitchen was powerwashed once a month. He stated that they would have to be more thorough when cleaning to ensure that all areas were cleaned.