HospitalInspections.org

Based on observation, record review and staff interview the facility failed to keep all essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition. Findings Include:

a) Observation on 1/7/25 revealed an appliance cord that served a kitchen refrigerator, spliced, with exposed wire connectors, to make the chord longer to reach a receptacle.

b) During record review on 1/08/25, findings revealed there was several failed damper tests with no corrective action for the following dampers:
i. ID- 08696
ii. ID- 08686

c) An observation on 1/7/25 at approximately 1:45 p.m.., revealed a sprinkler heads (3) in the Kitchen, near the dish area, that were corroded.

d)An observation on 1/7/25 at approximately 11:38 a.m., revealed a hood extinguishing system without proper extinguishing coverage over the griddle.

e)Record review on 1/8/25 at approximately 9:00 a.m. revealed the facility failed to ensure that the fire rated doors in Hospital were inspected annually.

f)Record review on 1/8/25 at approximately 10:35 a.m.., revealed no current documentation for testing of the physical integrity, correct polarity, continuity of the grounding circuit, or retention force for each electrical receptacle at the patient bed locations in the facility.

g) These findings were verified during an exit interview with the Maintenance Director,and CEO on 1/09/25 at 11:30 a.m.

Based on observation on 1/7/25 the facility failed to keep and maintain a sanitary, safe, and presentable environment.

These findings include:

a) During observation on 1/7/25 at 2:00 p.m. revealed paint peeling from the wall in the kitchen that was above clean and dirty dishes.

b)) These findings were verified during an exit interview with the Maintenance Director,and CEO on 1/09/25 at 11:30 a.m.

Based on observation, document review, and staff interview, the facility failed to ensure that all food items were properly stored after the package was opened and all food items were properly dated when opened for patient consumption. This failure has the potential to adversely affect all patient receiving meals at the facility.

Findings are as follows:

An observation was conducted on 01/07/25 at 3:20 p.m. of the kitchen area, accompanied by Employee #2 and Employee #3. In the kitchen area near a six (6) burner stove had a counter space connected to the stove surface. Directly above the counter space there was a shelf that had five (5) packages of assorted types of bread and buns, that included, but not limited to: two (2) loaves of raisin bread, one (1) package hamburger buns, two (2) loaves of white sliced bread which was opened and undated.

An observation was conducted on 01/07/25 at 3:35 p.m. of the dry food storage area, accompanied by Employee #2 and Employee #3. The dry goods area was noted to have an open bag of partially used Oreo medium cookie pieces which some of the cookie pieces were hanging out of the open bag and no date on the open package. A Kool-Aid Twists were opened without a date. Also, was noted to have open cases of small can sodas that did not have a date when the case was opened for consumption, that included, but was not limited to:

One (1) case of Shasta Root beer Soda which had four (4) unopened sodas not dated left within this case, one (1) case of Shasta Ginger Ale which had eight (8) unopened sodas not dated within this case, and one (1) case of Shasta Twist of eight (8) unopened sodas not dated within this case.

A document titled: "Food and Nutrition Services 'Used By' Dating Guidelines" undated; was reviewed and stated in part: "The following is a guide to use when establishing a "Use By" date for food items...Guideline assume that food is properly stored, covered and handled.

An interview was conducted on 01/07/25 at 3:25 p.m. with Employee #2, who confirmed that the bread and buns on the shelf was opened today during meal preparation which was not dated when opened.

An interview was conducted on 01/07/25 at 3:40 a.m. with Employee #2, who confirmed that the Oreo Medium cookies pieces were not properly stored when opened and not dated, Kool-Aid Twist were not properly dated when the case was opened, and the Soda cases had unopened sodas left in the cases which was not properly dated when the soda cases where opened. Employee #2 stated, "When all these cases were opened, they should have been dated properly when opened."

An interview was conducted on 01/8/25 at 1:25 p.m. with Employee #1, who confirmed that the "Food and Nutrition Services 'Use By' Dating Guidelines is consider the guidelines or policy we use for dating and storage of food."