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.

SUNDANCE HOSPITAL 7000 US HIGHWAY 287 ARLINGTON, TX 76001 April 17, 2018
VIOLATION: GOVERNING BODY Tag No: A0043
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation interview and record review the Governing Body failed to:

a.) Effectively monitor the facility's Food and Dietetic Services when the Contracted Food Services was not included in the facility's Environment of Care rounds and the Kitchen was not being maintained in a sanitary manner.

b.) Implement and enforce an effective Facilities Maintenance Repair system when three patient hand sinks where reportedly malfunctioning and had not been fixed in over a year.

Findings Include:

a.) Observations on 4/16/18 at 4:10 p.m. of the facility's Dietary Department revealed:
- Copious amounts of Noodles, meat and debris in the floor drains
- Two convection ovens, with burnt on food debris
- 6 dirty and wet towels laying on the floor and counters and under cutting boards.
- An opened package of instant pudding mix sitting next to raw chicken being cut and prepared.
- Table top mixer with copious amounts of dried on food debris
- The three-hole-sink's Sanitizer sink, the last stage of cleaning, was full of pots and pans, the water was dirty and grease was noted floating on the top of the water.
- Black mold was growing along the back of the three-hole-sink's edge and wall
- The hot steamtable had dried food debris along the sides and there was floating food debris in the holding water, left over from the lunch meal.
- The large sugar, flour and rice bins had open bags sitting on dried food debris. The flour bag had a Styrofoam bowl that as being used to scoop out the flour.
- The portable reach-in refrigerator had trays of food that were not labeled or dated.
- The Walk-in refrigerator's floor was littered with food debris and Ground Beef, raw chicken, cooked noodles, chopped onions and Turkey did not have expiration dates and French dip steak, coleslaw, Roast Beef and peaches food products were dated as expired on [DATE] and were available for use.
- The Facility's Walk-in Freezer's floor was littered with food debris and a large pan of Taco Meat was inappropriately stored, allowing the meat to become freezer burnt and pieces of clear plastic fell into the meat.
- The Facility's Dry Food Storage had food debris on the lower shelf coverings and a bag of powdered sugar, basil and bay leaves were stored open.
- The Kitchen's floors were blackened with caked on dirt and food debris.
- The Hood filters where coated with a large amount of grease, making for a potential fire hazard.


During an interview on the afternoon of 4/16/18, in the Kitchen, Staff #9 Dietary Manager confirmed the findings and stated, " ...The items should be dated when placed in the refrigerator, it's good for three days.... These should be thrown out .... We are a contracted food service company ...."

During an interview on the afternoon of 4/16/18, in the Kitchen, Staff #8, Regional Dietary Manager, when asked how often the kitchen is checked for cleanliness stated, "We check routinely .... I haven't been here in two weeks." When asked if he participates in the Facility's Quality Meetings stated, "No."

During the tour of the Dietary Department Staff #7, Environmental Services Director confirmed the findings and when asked who inspects the kitchen from the facility stated, "I'm probably going to be overseeing the Kitchen." Staff #7 confirmed he does not have a background in foodservice.

During an interview on the afternoon of 4/16/18, Staff #5, Director of PI/Quality when asked if the Dietary Department was being monitored and reported to the Governing Body for review stated, "No ...the EOC (Environment of Care) was supposed to be submitting the reporting and auditing piece of the Dietary. ...there isn't a PI (performance improvement) for the kitchen .... dietary was one of the areas that was lacking .... The RD (registered dietitian) does monthly reports, it goes to the Administrator ...."

Review of the facility provided Kitchen Self Inspection Checklist, completed by the Registered Dietitian reflected:
1/31/18 ...foods prepared on site clearly labeled with product name and use-by-date: Not Acceptable ...appliances dirty, expired food ..."
2/26/18 ... foods prepared on site clearly labeled with product name and use-by-date: Not Acceptable ...Oven/appliances need to be cleaned ... Kitchen needs a good cleaning on walls, appliances, and shelves ...."
3/30/18 ... foods prepared on site clearly labeled with product name and use-by-date: Not Acceptable ...oven still needs to be cleaned ...will focus on more thorough walk thru with new manager in April."

Review of the facility provided policy Sanitation General Policies for Employees (dated November 1, 2010) reflected:
Purpose: To define responsibility for keeping the kitchen and cafeteria clean and sanitary.
Procedure: The following rules and regulations are to be followed by all FANS staff in order to maintain a clean, sanitary and safe environment ...Utensil drawers are to be kept clean and organized at all times with only those items assigned to
the drawers in those drawers .... 10. All work tables, including legs and tables, are to be thoroughly cleaned and sanitized by each employee who uses the area before that employee leaves for the day ....11. The entire kitchen floor will be totally cleaned and sanitized at the end of each day using established procedure.

Review of the facility provided policy Procedure for cleaning kitchen floor (dated November 1,2010) reflected:
Purpose; To outline the procedure used in cleaning the kitchen floor in order to ensure a clean, sanitary environment.
Procedure: 1. Responsibilities
a. The FANS Supervisor is responsible for training personnel on this procedure and monitoring
adherence to it .... c. The Aides are responsible for scrubbing the floor every evening.
3. After all food service activities are complete each day the Aide will scrub the entire kitchen with an automatic scrubber and a floor cleaner, which is approved for use on kitchen floors ...."

Review of the facility provided cleaning schedules reflected the Cleaning Schedule was completed on 1/1/2018.

b.) Observations of the facility's busy reception area on 4/16/18 at 3:23 p.m. revealed the lobby restroom's hand rails, next to the toilet, with an 8-inch smear of brown substance on the rail and wall and the lobby trashcan was overflowing with trash. The surveyor reported the condition of the restroom to the receptionist at 3:25 p.m. The restroom was not blocked off to prevent further patients and the public from accessing the restroom.

During an interview on the afternoon of 4/16/18 at 4:00 p.m. Staff #7, EVS (Environmental Services) director stated, "It probably hasn't been cleaned yet." The restroom was locked and a small child's voice could be heard in the restroom.

Review of the facility provided Patient's Bill of Rights reflected, " ...3. You have the right to a clean and humane environment in which you are protected from harm ..."

Review of the Sundance Maintenance Logs dated 12/13/16 reflected Room 337, 331 and 319 Sink not working. The Log did not reflect a repair completion date.

Observation during a tour of the adolescent male unit revealed the faucets in room 332, 331 and 319 did not work.

Review of the Sundance Maintenance Logs dated 2/5/18 reflected Adult/209 Light Not working.

Observation during a tour of the Adult inpatient unit revealed the Light in room 209 was not working.

During a tour of the adolescent male unit when asked to see the Maintenance Log the nursing manager and the Maintenance Director could not find the Maintenance Log for the unit.

During an interview in the afternoon of 4/16/18 Staff #7, Maintenance Director confirmed the findings and stated, "The facility doesn't have a formal reporting system .... They don't have work orders."

Review of the facility provided policy MAINTENANCE REQUESTS (revised7/29/13) reflected,
Policy: Sundance Behavioral Healthcare shall be provided with preventative and as needed maintenance service from the Plant Operations Department of Sundance Hospital.
Procedure:
1. All maintenance needs are to be coordinated through the Administrator.
2. The Plant Operations Director of Sundance Hospital will be notified of the request for service and given an indication of the priority need for the work.
3. The Sundance Hospital Plant Operations Director will coordinate completion of the work and communicate with the Sundance Behavioral Healthcare Administrator the expected date of completion.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation and interview the facility failed to provide care in a safe setting when the patient restroom was left dirty and accessible to patients and visitors.

Findings Include:

Observations of the facility's busy reception area on 4/16/18 at 3:23 p.m. revealed the lobby restroom's hand rails, next to the toilet, with an 8-inch smear of brown substance on the rail and wall and the lobby trashcan was overflowing with trash. The surveyor reported the condition of the restroom to the receptionist at 3:25 p.m. The restroom was not blocked off, to prevent further patients and the public from accessing the restroom.

During an interview on the afternoon of 4/16/18 at 4:00 p.m. Staff #7, EVS (Environmental Services) director stated, "It probably hasn't been cleaned yet." The restroom was locked and a small child's voice could be heard in the restroom.

Review of the facility provided Patient's Bill of Rights reflected, " ...3. You have the right to a clean and humane environment in which you are protected from harm ..."
VIOLATION: FOOD AND DIETETIC SERVICES Tag No: A0618
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation interview and record review the facility failed to ensure food services was being provided in a sanitary manner.

Findings Include:

Observations on 4/16/18 at 4:10 p.m. of the facility's Dietary Department revealed:
- Copious amounts of Noodles, meat and debris in the floor drains
- Two convection ovens, with burnt on food debris
- 6 dirty and wet towels laying on the floor and counters and under cutting boards.
- An opened package of instant pudding mix sitting next to raw chicken being cut and prepared.
- Table top mixer with copious amounts of dried on food debris
- The three-hole-sink's Sanitizer sink, the last stage of cleaning, was full of pots and pans, the water was dirty and grease was noted floating on the top of the water.
- Black mold was growing along the back of the three-hole-sink's edge and wall
- The hot steamtable had dried food debris along the sides and there was floating food debris in the holding water, left over from the lunch meal.
- The large sugar, flour and rice bins had open bags sitting on dried food debris. The flour bag had a Styrofoam bowl that as being used to scoop out the flour.
- The portable reach-in refrigerator had trays of food that were not labeled or dated.
- The Walk-in refrigerator's floor was littered with food debris and Ground Beef, raw chicken, cooked peaches food products were dated as expired on [DATE] and were available for use.
- The Facility's Walk-in Freezer's floor was littered with food debris and a large pan of Taco Meat was inappropriately stored, allowing the meat to become freezer burnt and pieces of clear plastic fell into the meat.
- The Facility's Dry Food Storage had food debris on the lower shelf coverings and a bag of powdered sugar, basil and bay leaves were stored open.
- The Kitchen's floors were blackened with caked on dirt and food debris.
- The Hood filters where coated with a large amount of grease, making for a potential fire hazard.


During an interview on the afternoon of 4/16/18, in the Kitchen, Staff #9 Dietary Manager confirmed the findings and stated, " ...The items should be dated when placed in the refrigerator, it's good for three days.... These should be thrown out .... We are a contracted food service company ...."

During an interview on the afternoon of 4/16/18, in the Kitchen, Staff #8, Regional Dietary Manager, when asked how often the kitchen is checked for cleanliness stated, "We check routinely .... I haven't been here in two weeks." When asked if he participates in the Facility's Quality Meetings stated, "No."

During the tour of the Dietary Department Staff #7, Environmental Services Director confirmed the findings and when asked who inspects the kitchen from the facility stated, "I'm probably going to be overseeing the Kitchen." Staff #7 confirmed he does not have a background in foodservice.

During an interview on the afternoon of 4/16/18, Staff #5, Director of PI/Quality when asked if the Dietary Department was being monitored and reported to the Governing Body for review stated, "No ...the EOC (Environment of Care) was supposed to be submitting the reporting and auditing piece of the Dietary. ...there isn't a PI (performance improvement) for the kitchen .... dietary was one of the areas that was lacking .... The RD (registered dietitian) does monthly reports, it goes to the Administrator ...."

Review of the facility provided Kitchen Self Inspection Checklist, completed by the Registered Dietitian reflected:
1/31/18 ...foods prepared on site clearly labeled with product name and use-by-date: Not Acceptable ...appliances dirty, expired food ..."
2/26/18 ... foods prepared on site clearly labeled with product name and use-by-date: Not Acceptable ...Oven/appliances need to be cleaned ... Kitchen needs a good cleaning on walls, appliances, and shelves ...."
3/30/18 ... foods prepared on site clearly labeled with product name and use-by-date: Not Acceptable ...oven still needs to be cleaned ...will focus on more thorough walk thru with new manager in April."

Review of the facility provided policy Sanitation General Policies for Employees (dated November 1, 2010) reflected:
Purpose: To define responsibility for keeping the kitchen and cafeteria clean and sanitary.
Procedure: The following rules and regulations are to be followed by all FANS staff in order to maintain a clean, sanitary and safe environment ...Utensil drawers are to be kept clean and organized at all times with only those items assigned to
the drawers in those drawers .... 10. All work tables, including legs and tables, are to be thoroughly cleaned and sanitized by each employee who uses the area before that employee leaves for the day ....11. The entire kitchen floor will be totally cleaned and sanitized at the end of each day using established procedure.

Review of the facility provided policy Procedure for cleaning kitchen floor (dated November 1,2010) reflected:
Purpose; To outline the procedure used in cleaning the kitchen floor in order to ensure a clean, sanitary environment.
Procedure: 1. Responsibilities
a. The FANS Supervisor is responsible for training personnel on this procedure and monitoring
adherence to it .... c. The Aides are responsible for scrubbing the floor every evening.
3. After all food service activities are complete each day the Aide will scrub the entire kitchen with an automatic scrubber and a floor cleaner, which is approved for use on kitchen floors ...."

Review of the facility provided cleaning schedules reflected the Cleaning Schedule was completed on 1/1/2018.
VIOLATION: ORGANIZATION Tag No: A0619
Based on observation, interview and record review the facility failed to provide the food and dietetic services in an organized manner.

Cross refer to A0619
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based in observation, interview and record review the facility failed to develop and maintain the hospital in a safe and sanitary environment when broken sinks were not repaired.

Findings Include:

Review of the Sundance Maintenance Logs dated 12/13/16 reflected Room 337, 331 and 319 Sink not working. The Log did not reflect a repair completion date.

Observation during a tour of the adolescent male unit revealed the faucets in room 332, 331 and 319 did not work.

Review of the Sundance Maintenance Logs dated 2/5/18 reflected Adult/209 Light Not working.

Observation during a tour of the Adult inpatient unit revealed the Light in room 209 was not working.

During a tour of the adolescent male unit when asked to see the Maintenance Log the nursing manager and the Maintenance Director could not find the Maintenance Log for the unit.

During an interview in the afternoon of 4/16/18 Staff #7, Maintenance Director confirmed the findings and stated, "The facility doesn't have a formal reporting system .... They don't have work orders."

Review of the facility provided policy MAINTENANCE REQUESTS (revised7/29/13) reflected,
Policy: Sundance Behavioral Healthcare shall be provided with preventative and as needed maintenance service from the Plant Operations Department of Sundance Hospital.
Procedure:
1. All maintenance needs are to be coordinated through the Administrator.
2. The Plant Operations Director of Sundance Hospital will be notified of the request for service and given an indication of the priority need for the work.
3. The Sundance Hospital Plant Operations Director will coordinate completion of the work and communicate with the Sundance Behavioral Healthcare Administrator the expected date of completion.