The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on medical record (MR) reviews, policies reviews, and interview with staff, it was determined the hospital failed to ensure the MR documentation was accurate and complete to indicate the patients' condition, treatments, and care provided during the hospital stay. Thus, the care providers were unable to access the correct and complete information to formulate the patients' care.

Findings include:

Refer to A 449.
Based on the review of the facility's policies and procedure, observations and interview, it was determined the hospital failed to ensure the dietary department provided a sanitary enviroment to store and perpare the patients nutritonal needs.

Findings Include:

Refer to A 619.
Based on the review of the facility's policies and procedure, observations and interview, it was determined the hospital failed to ensure:

1. The dietary department was operated in a sanitary manner.

2. Staff followed the facility's polices and procedures for sanitation solutions and nonfood contact surfaces.

This had the potential to negatively affect all patients served by this hospital.

Findings include:

Facility Policy: Section: Sanitation and Infection Prevention/Control
Subject: Sanitizing Food Contact Surfaces
Policy #: F018
Date Issued: 5/95
Date Revised: 1/18


"Moist cloths used for wiping food spills shall be clean and rinsed frequently in a sanitizing solution used for no other purpose. These cloths shall be stored in the sanitizing solutions between uses.

Sanitizing solution must be at 200 PPM (parts per million) to 400 ppm for Oasis 146 Multi-Quat Sanitizer, Mikroklene solution..."

Facility Policy: Section: Sanitation and Infection Prevention/Control
Subject: Cleaning of Food and Nonfood Contact Surfaces.
Policy #: F013
Date Issued: 5/95
Date Revised: 1/17


Food contact surfaces are in good condition, made of non-toxic materials and are easily cleanable.

Nonfood Contact Surfaces:

...Nonfood contact surfaces of equipment, such as handles on reach-in units, sides of sinks, gaskets on cooler and freezer doors, tracks of sliding doors on equipment, and the Exterior of the ice machines, shall be cleaned as often as is necessary to keep equipment free of accumulation of dust, dirt, food particles, and other debris.

Facility Policy: Section: Production , Purchasing, Storage
Subject: Food and Supply Storage
Policy #: B003
Date Issued: 5/95
Date Revised: 1/18


All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption....


...Cover, label and date unused potions and open packages.

During observation of care on 8/6/18 at 11:25 AM, an unsampled patient's significant other came to the nurses' station on 4 th floor and reported the baked chicken in room 546 was raw. The surveyor observed a baked leg and thigh, which had pink meat, easily pulled apart with a fork and dark spots near the bone joints.

The surveyor went to the kitchen on 8/6/18 at 11:45 AM and asked for the person who cooked the chicken. Employee Identifier (EI) # 11, Kitchen Staff, stated, "I cooked the chicken today. I normally do not cook the chicken but I did today". The surveyor asked EI # 11, "what is the process was for making sure the chicken is cooked properly". The response was, "We defrost the chicken in the sink with water, place the defrosted chicken on a pan and place it in the refrigerator until it is time to cook. We cook in the oven at 350 degrees for 45 to 55 minutes, when it reaches 165 to 170 degrees internal". The surveyor asked EI # 11 if the temperature was documented anywhere and the response was, "not documented".

The surveyor asked EI # 11, if there was any chicken left to test the temperature and the response was, "yes in the oven". The surveyor asked EI # 11 to measure the temperature of the baked chicken.

EI # 11 did not have a thermometer and went to borrow one from another kitchen staff. EI # 11 took the borrowed thermometer to the red bucket of sanitizer solution, which was under the plating table and contained a towel. EI # 11 stated he/she was going to clean the thermometer with the solution in the red bucket. EI # 11 tested the solution and the results were 150 PPM.

EI # 11 used an alcohol pad to clean the thermometer. EI # 11 checked the chicken temperature and the results were 187 degrees.

During the assessment of the chicken temperature on 8/6/18, the surveyor observed the kitchen floor to be saturated with water and had chunks of food on the floor. There was a serving spoon being used as a door stop. The hand washing sinks were dirty and stained with no trash receptible to place the towels used to dry hands.

A tour of the kitchen was conducted on 8/7/18 at 9:45 AM with EI # 12, Dietary Director. The following issues were identified:

1. The floors were wet with chunks of food on the floor.

2. Food Carts used to transport food trays to the patient areas were dirty on the inside and outside. The seals were broken allowing heat to escape.

3. Food that was prepared to go to the patient care areas was uncovered.

4. Freezer for ice cream had built up ice at least 2 inches thick.

5. The grill had burnt brown baked on food and grease.

6. Hoods had built up grease with dust.

7. Ovens doors were covered with baked on food and grease.

8. The steam table area had chunks of food and water all on the floor. There were 2 colanders to catch food to keep it from going down the drain. The piping was leaking and spraying all over the wall. The wall had multiple black spots.

9. The walk in refrigerator had spills on the walls, gaskets around the edges of the door had grime and food crumbs. There was raw meat uncovered on pans which were visibly stained with baked on grease. There was uncovered lettuce, pudding, and pan of chicken which was partially wrapped.

10. There was chipped paint flaking off the walls and ceiling.

11. Clean plates stacked in plate holders ready for the staff to plate food for the patients with stains and crumbs of food on the bottom.

12. No kick plates on the doors.

13. Hand washing sinks with no trash receptacle and/or paper towels to dry hands. Sinks had stains on all sides on the inside and outside.

14. Containers of seasoning in the dry area with seasoning all over the floor and container.

15. There were 4 pots and pans stored in the clean storage area wet nested and/or not thoroughly cleaned - greasy to touch. In addition to the the pots and pans there were 2 full and half sheet baking pans that were stored wet nested and greasy to touch.

The surveyor returned to the kitchen on 8/8/18 at 11:20 AM to interview EI # 12 concerning the plans on replacing the steam table. The transport carts had not been cleaned, the floors were still wet with chunks of food, and the cooler had not been cleaned. This was an abbreviated tour.

EI # 12 stated the equipment to replace the steam table had been priced and submitted to Plant Operations to assess comparability with the gas and current set up. There were no other plans at this time to replace the steam table.