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Based on review of CRRH (Conway Regianl Rehabilitation Hospital) Tray Audit reports, review of the Arkansas Rules and Regulations for Hospitals and Related Institutions, 2016, and interveiw, it was determined the director of food services failed to perform daily management of dietary services to assure safe practices for food handling in that of food temperatures on the patient trayline were not taken before and after every meal in 92 of 98 (10/01/19-01/06/20) days. The failed practice did not allow the kitchen staff to know if hot foods were above 140 degrees Fahrenheit and cold foods were less than 40 degrees Fahrenheit through the duration of the tray line service. The failed practice had the potential to affect anyone receiving food from the dietary service. Findings follow:

A. Review of Arkansas Rules and Regulations for Hospitals and Related Institutions, 2016, showed temperatures of hot and cold foods on the patient trayline was to be taken at the beginning of each meal and at the end of each meal in which trayline lasted longer than 15 minutes.
B. No policy was presented concerning tray audits or temperatures.
C. Review of CRRH Tray Audit forms for 10/01/19 through 01/06/120 showed there was no documentation as to how long trayline lasted at each meal. Therefore, it was unknown as to whether or not food temperatures should be taken at the end of trayline.
D. Review of CRRH Tray Audit forms for 10/01/19-01/07/19 showed trayline temperatures missing for the following meals:
1) October 2019-there was no evidence of trayline temperatures taken before or after breakfast, lunch and dinner on 10/0122/19 and 10/24-31/19.
2) November 2019-there was no evidence of trayline temperatures taken before or after breakfast, lunch and dinner on 11/01-13/19, 11/15-26/19, and 11/28-30/19.
3) December 2019-there was no evidence of trayline temperatures taken before or after breakfast, lunch and dinner on 12/01-04/19, 12/06-23/19 and 12/25-31/19.
4) January 2020-there was no evidence of trayline temperatures taken before or after for breakfast, lunch and dinner on 01/01-06/20.
5) On 10/23/19, there was no evidence of trayline temperature checks prior to lunch and dinner.
6) On 10/07/19, 11/04/19 and 11/27/19, there was no evidence of trayline temperature checks prior to breakfast and dinner.
7) On 12/05/19, there was no evidence of trayline temperature checks prior to breakfast and lunch.
8) On 12/24/19, there was no evidence of trayline temperature checks prior to lunch.
E. During an interveiew on 01/07/20 at 10:00 AM, the Dietary Manager verified findings in B, C, and D.

Based on observation, interview, and review of National Fire Protection Association (NFPA) 99, 5.1.3.3.1.6(3) standards, it was determined the facility failed to ensure supplies and equipment were maintained in an acceptable level of safety and quality in that 12 of 12 256 cubic feet of full oxygen tanks were being stored in the maintenance room with combustible items (aerosol cans, 5 gallon paint container and ceiling tiles). The risk of an explosion had the likelihood to affect all patients, visitors and staff in the facility. Findings follow:

A. Review of NFPA 9, 5.1.3.3.1.6(3) where indoor locations of for oxygen, nitrous oxide and mixtures of these gases shall not be stored adjacent to flammables.
B. Observations on 01/7/2020 at 9:00 AM of the maintenance room showed 12-256 cubic feet oxygen tanks were stored in the maintenance room with combustible items (aerosol cans, 5- gallon paint container and ceiling tiles.
C. The above finding in B were verified 01/7/2020 at 9:15 AM by the Director of Operations.