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Based on observation, record review, and interviews the Governing Body failed to ensure the facility provided a clean environment for patient food preparation and service. The Infection Control Officer failed to monitor the kitchen for cleanliness and food safety. The facility failed to monitor the contracted kitchen service to ensure cleanliness of the kitchen environment. Failure to provide a clean environment for food preparation and service can lead to a food borne illness.

Refer to Tag A0749

Based on observation, record review, and interviews the facility failed to provide a clean environment for patient food preparation and service.The Infection Control Officer failed to monitor the kitchen for cleanliness and food safety. The facility failed to monitor the contracted kitchen service to ensure cleanliness of the kitchen environment. Failure to provide a clean environment for food preparation and service can lead to a food borne illness.

Refer to Tag A0749

Based on observation, record review, and interviews the facility failed to provide a clean environment for patient food preparation and service. The Infection Control Officer failed to monitor the kitchen for cleanliness and food safety. The facility failed to monitor the contracted kitchen service to ensure cleanliness of the kitchen environment. Failure to provide a clean environment for food preparation and service can lead to a food borne illness.

A tour was taken of the patient care area on 3/23/16 with staff #1 and #2. The following patient care areas and nursing medication rooms revealed the following infection control issues:

1. The medication room on the 200 unit (Geriatric Unit) had tape and dust found on the medication refrigerator. A dusty fan was blowing on medication preparation area and clean medication cups were sitting next to sink for hand washing, under the dirty needle disposal. Splattered red substances noted on medication cups.

2. Hard water build up on sink faucet in the 200 medication room. No labels on the filled water pitcher. The trash can in medication room spattered with a brown substance and trash noted on floor around the can.

3. Back board noted on floor siting by trash can. A brown dried substance splattered all over the back board and floor.

4. Dyna Map machine dirty and soiled sitting in medication room on the adult unit. Bottom of the unit was soiled in dirt and hair. Medication room on the adult unit had a medication refrigerator sitting on the floor. The inside door and shelves were covered in dust and hair. Medication Pyxis on the adult unit was soiled on the inside and outside with dust and hair. The floor was soiled by the trash can with dried liquid substances and dirt. The crash cart along with the suction canister was uncovered and dusty.

5. Patient room #408 was reported as a terminally cleaned room. Bathroom of #408 had baseboards separating from the wall and mildew substance in the shower.

6. All the bases to the beds in the patient' s rooms to all units have wooden bases that have not been sealed. Food and trash was found in the base of a patient bed in room 408. This room was designated as clean and ready for a new patient. A black substance was found around the light fixture on ceiling. The toilet was covered in dust, hair and feces. There was dried urine in bowl. The shower had a dried yellow substance around the drain.

7. Patient room 402 was considered a terminally cleaned room. The bathroom floor and shower was covered in multiple hairs. The toilet was stained with dried urine and hair.

An interview was conducted with staff #1 and #2 on 3/23/16. Staff #1 and #2 confirmed the above findings. Staff #1 called in housekeeping and nursing to clean the areas. Staff #1 stated he did not think to look in these areas during the environmental rounds.

A tour was taken of the patient care area on 3/23/16 with staff #1 and #2. The tour led into the dining room area. The floors were noted to be soiled in the dining room with large amount of dust noted around the kitchen door. A tour of the kitchen revealed the following infection control issues:

A. The door frame to the kitchen entrance from the dining room was soiled with dust and dirt. The threshold to the kitchen from the hallway was soiled with grease and dirt substance.

B. In the dishwashing area of the kitchen the floor and drains were soiled with dried liquids and build up of dirt and dust.

C. The mop room in the kitchen was found to be soiled with dirt and hair. Clean uniforms were stored in the mop room that employees wore in the clean preparation area. Open and exposed mops and towels were found on the shelf.

D. Refrigerator and freezer had shipping boxes on the shelves. The threshold to the refrigerator and freezer was soiled with dirt and dust.

E. The leg to a rolling cart in the food preparation area was soiled with dried liquids and rust.

F. Apples were found mildewed in the food storage area.

G. 12 Stacked pans were found wet and with food particles inside of pans.

H. The top of the microwave was soiled with a greasy substance and dried food particles. The microwave was soiled on the inside with a build- up of a greasy substance and dried food particles. A hand mixer found in a box on top of the microwave was soiled with dried food and dust. A bag was found on the microwave with Christmas CD's inside. The CD's were soiled with a greasy substance and the bag holding the CD's was covered in dust.

I. A chafing dish on the clean rack was soiled with a greasy substance, food particles and tarnished.

J. A hand mixer was found open sitting on a bottom shelf of a clean dish rack below the microwave. The mixer along with plastic containers were found to be covered in a greasy substance, food particles and dust.

K. Clean containers used for food storage were found on a bottom rack in the food preparation area. There was no barrier between the containers and the floor. The containers were soiled with food particles, greasy substance, and dust.

L. A drain in the floor in the food preparation area was found soiled with a, black gooey substance mixed with hair, and dead bugs.

M. A food scale in the food preparation area was found to be covered in dust and hair.

N. The knife holder and knife handles used for food preparation were found greasy, and covered with food particles.

O. A commercial mixer was found covered with a plastic cover. The cover was removed and a soiled mixer was found with food particles, dried substances, and dust. The kitchen supervisor reported it was supposed to be clean and ready for use.

P. Condiments and spices were found on a bottom shelf in the food preparation area covered in spilled dried liquids, food particles, with no dates of opening or expiration.

Q. Metal shelves were found in the food preparation area covered in dried liquids, food particles, and rust. A rolling shelf in the food preparation area was covered in a greasy substance with dust and food particles.

R. The double door oven in the kitchen was found to be covered in a greasy substance, spilled and dried liquids, food particles and dust. The inside of the oven was soiled and covered in a greasy substance with dried and baked on splatters of spilled liquids. The racks to the oven were found sitting on a soiled floor with no barrier.

S. The kitchen stove was soiled with a greasy substance, burned on liquids, food particles, and dust on the knobs. The back splash was scorched and covered in carbon. Oven under stove was soiled with dried liquids and food particles.

T. Cheese was found in the refrigerator uncovered with no opening date. The metal container holding the cheese was soiled with food particles and dried liquids.

U. The legs to the sink basin in the food preparation area was soiled with a greasy substance, dust, dirt, and food particles. The drain in the floor, under the sink, had a layer of a black thick substance on the floor and drain.

V. A can opener was found in the food preparation area rusted and soiled with food particles.

X. The food preparation table was rusted and soiled with dried liquids and food particles. Bins of dry goods sat underneath this table. Plastic containers found of dried goods; beans, corn meal, rice, and a bag of sugar had no opening date. The containers were soiled with grease, food particles, and dust. A bin with white flour was found in the food preparation area soiled with dried liquids and food particles. There was no opening date found.

Y. Gas valves in the kitchen food preparation area was covered in dust and grease.

Z. Lids for the patient trays were on the clean shelf with patient labels still attached leaving a sticky surface. A bin of utensils were sitting in the clean dish area. The bin was soiled with dust and food particles.


An interview with staff #17 on 3/23/16 revealed the dirty soiled mop room was where the employees were getting their clean uniforms. Staff #17 confirmed they were stored in there with the dirty supplies and had no other place to store the uniforms. The kitchen supervisor was asked how and what he reported to QAPI. Staff #17 reported that he did take information to Quality Assessment Performance Improvement (QAPI) for problems in the kitchen but had not identified the environmental issues.

An interview was conducted with staff #1 and #2 on 3/23/16. Staff #1 stated that he would have a professional cleaning team to come into the facility overnight and have the kitchen cleaned. On 3/24/16 another tour of the kitchen was conducted. The kitchen had improved in cleanliness but no infection control reports or plans had been initiated.

An interview with staff #20 on 3/24/16 revealed staff #20 had not been in the kitchen to round on environmental issues.