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Based on review of facility documentation, personnel file review (PF), and a facility tour, it was determined that there was a risk for patients, visitors, and staff of developing food born illness/illnesses when the facility failed to ensure there was a system being implemented for monitoring of temperature regulation and expiration of food products within the Dietary Department.

Findings include:

1. On March 21, 2025, a tour of the Dietary Department did not reveal food items within the Dietary Department to include consistent documentation of expiration dates. Further observation revealed approximately 21 boxes of food sitting on the floor of the walk-in freezer, blocking easy access to the freezer entryway. Additional expired food items were identified during a tour of the nutritional rooms on the patient care units.

2. An Immediate Jeopardy was called at 1:28 PM on March 21, 2025, when it was determined that patients, visitors, and/or staff were at risk for developing food born illness/illnesses based on the practices being implemented within the Dietary Department.

3. The Immediate Jeopardy (IJ) was resolved at 5:04 PM on March 21, 2025, when the facility submitted an immediate action plan which included an immediate internal tour of the Dietary Department, education of applicable facility policies for applicable employees prior to the next scheduled shift, and immediate initiation of daily and monthly audits. State Survey Agency verified implementation of an acceptable IJ removal plan.

Cross referenced:
§482.28(a)(1) Director of Dietary Services

Based on review of facility documentation and a facility tour, as well as employee interviews (EMP), it was determined that the facility failed to ensure that the established policies for food safety were being implemented within the Dietary Department and nutrition rooms.

Findings include:

Review, at approximately 12:30 PM on March 21, 2025, of facility policy FN-FP03 "Storage of Food and Supplies," revised January 1, 2021, revealed, "... Food and supplies shall be stored in such a manner as to prevent chemical, bacterial or other contamination and to ensure safety and preserve their quality. ... 1. Dry Storage: ... f. Food must be rotated using the First-In, First-Out (FIFO) method so that those with the earliest use-by or expiration dates are used first. ... h. Food will be clearly labeled as to content and opened food will be date marked according to Policy FN-FP04; i. Discard food that has reached its used-by or expiration date; ... 2. Cooler and Freezer: ... f. Do not overload or crowd cooler or freezer which prevents the free circulation of cooled air. ... h. Store items at least 6 inches from the floor or above on clean shelves, racks, or other clean surfaces. Food and supplies are to be protected from splash, dust or other contamination; i. Opened food shall be date marked and stored in containers intended for food which are durable, leak proof and able to be sealed or covered; j. Discard food that has reached it's use-by or expiration date. ..."

Review, at approximately 12:41 PM on March 21, 2025, of facility policy FN-FP04 "Food Safety," revised January 1, 2021, revealed, "... 3. Handling Leftovers: a. Only use leftover TCS if cooked, held, cooled and stored properly; b. Leftovers should be placed in covered containers and date marker; c. Use leftover TCS foods within 7 days with day 1 being the day the food was prepared; d. For opened foods follow the USDA Food and Beverage storage guidelines; 4. Date Marking: a. After opening or placing in container, food is to be marked with the following information: i. Common name of food; ii. Date opened or prepared; iii. Use by or discard date; b. It is the responsibility of the Food Service Director/Manager to follow their local and state guidelines. ..."

Review, at approximately 12:48 PM on March 21, 2025, of facility policy FN-FP05 "Food Preparation," revised January 1, 2021, revealed, "... To establish general guidelines to ensure prepared food is of highest quality, flavor, appearance and temperature, conserving nutritional value and minimizing bacterial contamination. ..."

Review, at approximately 1:00 PM on March 21, 2025, of facility policy FN-FD04 "Retail Food Service," revised January 1, 2021, revealed, "... To ensure a high-quality dining experience for customers, the retail area will be properly staffed to maintain cleanliness and handle and display food in a safe manner to maintain freshness and quality. Facilities will follow all local, state and federal guidelines. ... 8. Temperatures of food are taken at the start and end of service or at least every 4 hours. A. Hot foods shall be kept 135 degrees F or above. B. Cold foods shall be pre-chilled to a temperature of 41 degrees F or below when placed on display for service and displayed in or on a refrigerated unit that maintains a temperature at 41 degrees F or below. C. Discard TCS food that is not 41 degrees F or lower or 135 degrees F or higher at 4 hour intervals. ..."

A tour of the Dietary Department was conducted between approximately 10:30 AM -11:10 AM on March 21, 2025.

1. Observation of a shelving unit located outside of the walk-in freezer and refrigerator revealed the contents to include a full box of original coffee creamer with an expiration date of September 27, 2024, 91 packages of single serve crackers within a storage container with a labeled expiration date of October 28, 2024, five single serve cereal containers with an expiration date of March 9, 2024, three single serve Italian dressing packages with an expiration date of October 22, 2024, six single serve fat free Italian dressing packages with an expiration date of February 24, 2025, and six single serve syrups within a storage container, with a labeled expiration date of January 16, 2025. EMP2 confirmed this finding at the time of observation. Further confirmed that the identified food items should have previously been discarded.

2. Observation of the walk-in freezer revealed the contents to include approximately 21 boxes of food products on the floor. Further observation of the area revealed an opened/non-sealed bag of sausage patties with no open and/or expiration date, a container with approximately 24 in-house packaged sliced ham, dated March 11, 2025, and a tray of approximately nine in-house packaged pork chops, labeled February 9, 2025. EMP1 was unable to verify if the labeled dates on the food items were the dates the items were prepared or the date the items should have been used by. EMP1 was unable to demonstrate knowledge of facility policy for monitoring of food products within the freezer.

3. Observation of the walk-in cooler revealed the contents to include seven bags of in-house sliced ham, dated March 7, 2025, two bowls of pre-pulled uncooked/thawed chicken without an expiration date, one bag of in-house sliced mozzarella cheese, dated March 8, 2025, three bags of in-house sliced mozzarella cheese dated January 13, 2025, one block of cheddar cheese, dated February 22, 2025, five blocks of hot pepper cheese, dated March 8, 2025, and three packages of non-labeled strawberry packages. EMP1 was unable to verify if the labeled dates on the food items were the date the items were prepared or the date the items should have been used by. EMP1 was unable to demonstrate knowledge of facility policy for monitoring of food products within the cooler.

4. Observation of the prep line area revealed the contents of the prep line cooler to include an uncovered and non-labeled tray containing three chicken nuggets and approximately two cups of French fries. Observation of and additional cooler revealed the contents to include approximately 12 unopened bags of frozen foods, including chicken tenders, tater tots, and zucchini sticks. Expiration dates were unable to be identified on the frozen foods included in the cooler. EMP1 confirmed this finding at the time of the observation.

5. Observation of the Café serving line did not reveal completion of current temperature logs for hot or cold foods. EMP1 confirmed temperature logs were not being completed at the time of the observation.

A tour of the nutrition rooms on the second and third floor (Patient Care Units), was conducted between approximately 11:10 AM and 11:30 AM on March 21, 2025.

6. A tour of the nutrition room on the second floor revealed six single serve grape jelly containers, seven single serve strawberry jelly containers, 12 single serve sugar free syrups, and 11 single serve containers of peanut butter. Expiration/discard dates were unable to be identified. EMP2 confirmed this finding at the time of observation. Further confirmed that the identified food items should have previously been discarded.

7. A tour of the nutrition room on the third floor revealed four single serve containers of reduced sugar grape jelly, three single serve containers of reduced sugar strawberry jelly and four single serve containers of cereal with an expiration date of March 9, 2025. Further observation of the area revealed an opened package of cookies, 12 single serve containers of honey, and 22 single serve containers of syrup. Expiration date/discard dates on the food items unable to be identified. EMP2 confirmed this finding at the time of observation. Further confirmed that the identified food items should have previously been discarded.

8. Review, at approximately 12:08 PM on March 21, 2025, of the expense receipts provided for the Dietary Department between May 23, 2023, and February 12, 2025, confirmed that foods were being purchased from retail grocery stores, which included but was not limited to foods requiring refrigeration. EMP1 confirmed that he/she was purchasing and transporting the foods from the retail grocery store to the facility. Further confirmed that temperature monitoring between time of purchase and arrival to the facility was not completed.

9. Review, at approximately 2:20 PM on March 21, 2025, of the personnel file for EMP1 revealed that he/she was placed on a 30-day action plan, effective November 1, 2023, for failure to complete duties as required. This finding was confirmed by EMP6 at the time of review.

Cross referenced:
§482.28 Food And Dietetic Services
§482.42(a)(2) Infection Control Program

Based on review of facility documentation and a facility tour, as well as employee interviews (EMP), it was determined that the facility failed to maintain a sanitary environment within the Dietary and nutrition rooms of the hospital.

Findings include:

Review, at approximately 1:55 PM on March 21, 2025, of facility policy FN-S02 "Cleaning & Sanitizing Food Service Equipment/Work Areas," revised January 1, 2021, revealed, "... C. Nonfood-contact surfaces, such as walls, ceilings, table legs, drains, floors, garbage cans and equipment exteriors must be cleaned regularly to prevent dust, soil and food residue build-up. i. Wash the surface with prepared cleaning solution; ii. Rinse with clean water. ... 7. Monitoring of the cleaning program, by informal inspection of the department, cleaning routine, cleaning schedule and input from staff is conducted daily by the Manager. The Manager should modify the master cleaning schedule as needed. ... 8. Employees will obtain and maintain appropriate sanitation certification(s) and comply with state and local regulations. ..."

Review, at approximately 2:05 PM on March 21, 2025, of facility policy FN-S03 "Ware-washing," revised January 1, 2023, revealed, "... All dishes, three-compartment sinks and dishwashing machine equipment must be properly cleaned and sanitized. Food service staff will utilize proper technique to avoid recontamination of sanitized dishes. ... 4. Dish Machine/Room Cleaning: B. Cleaning process: ... l. Clean walls and floors daily. ..."

A tour of the Dietary Department was conducted between approximately 10:30 AM -11:10 AM on March 21, 2025.

1. Observation of the dishwashing room revealed a black residue on the floor tiles surrounding the dishwasher. Further observation of the area revealed non-disposed food particles within the sink. EMP1 confirmed this finding at the time of observation.

A tour of the nutrition rooms on the second and third floor (Patient Care Units), was conducted between approximately 11:10 AM and 11:30 AM on March 21, 2025.

2. Observation of the nutrition room on the second floor revealed a non-intact surface area behind the sink. Further observation revealed dried coffee-like substance on the counter. EMP2 confirmed this finding at the time of the observation.

3. Observation of the nutrition room on the third floor revealed a non-intact surface area behind the sink. EMP2 confirmed this finding at the time of the observation.

4. Review, at approximately 12:08 PM on March 21, 2025, of the expense receipts provided for the Dietary Department between May 23, 2023, and February 12, 2025, confirmed that foods were being purchased from retail grocery stores, which included but was not limited to foods requiring refrigeration. EMP1 confirmed that he/she was purchasing and transporting the foods from the retail grocery store to the facility. Further confirmed that temperature monitoring between time of purchase and arrival to the facility was not completed.

5. Review, at approximately 2:30 PM on March 21, 2025, of the "2024 Annual Evaluation of the IC Program and IC Plan for 2025," no date provided, did not reveal content of the document to include review of the Dietary Department. On March 25, 2025, EMP3 confirmed that review of the Dietary Department was not routinely reviewed as part of the infection control process.

6. Review, at approximately 2:20 PM on March 21, 2025, of the personnel file for EMP1 revealed that he/she was placed on a 30-day action plan, effective November 1, 2023, for failure to complete duties as required. This finding was confirmed by EMP6 at the time of review.

Cross referenced:
§482.28(a)(1) Director of Dietary Services