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Based on observation, interview and policy review, the hospital failed to ensure:
- Staff performed hand hygiene (washing hands with soap and water or alcohol-based hand sanitizer) when providing care for 14 patients (#4, #6, #7, #8, #9, #10, #11, #12, #13, #20, #37, #38, #39 and #40) of 17 patients observed.
- Staff prepared a clean work surface prior to performing patient care for 14 patients (#4, #6, #7, #8, #9, #10, #11, #12, #13, #20, #37, #38 #39, and #40) of 17 patients observed.
- Food items located in the kitchen refrigerator, kitchen freezer and the dry goods area were properly dated.
- Expired food items were removed from the kitchen refrigerator.
- Surfaces and equipment in the kitchen were properly cleaned.
- The dairy cooler temperature was maintained.
- Frozen meat was properly thawed out in the refrigerator.
- Prepared leftover foods were properly labeled, dated and stored in the refrigerator or freezer within 30 minutes of being serving.

These failures had the potential to expose all patients, visitors and staff to cross contamination and increased the potential to spread infection. The hospital census was 76.

The severity and cumulative effects of these systemic practices resulted in the hospital's non-compliance with 42 CFR 482.42 Condition of Participation: Infection Prevention and Control and Antibiotic Stewardship Programs and resulted in the hospital's failure to ensure quality health and safety. Refer to A-0749 for details.

Based on observation, interview and policy review, the hospital failed to ensure:
- Staff performed hand hygiene (washing hands with soap and water or alcohol-based hand sanitizer) when providing care for 14 patients (#4, #6, #7, #8, #9, #10, #11, #12, #13, #20, #37, #38, #39 and #40) of 17 patients observed.
- Staff prepared a clean work surface prior to performing patient care for 14 patients (#4, #6, #7, #8, #9, #10, #11, #12, #13, #20, #37, #38 #39, and #40) of 17 patients observed.
- Food items located in the kitchen refrigerator, kitchen freezer and the dry goods area were properly dated.
- Expired food items were removed from the kitchen refrigerator.
- Surfaces and equipment in the kitchen were properly cleaned.
- The dairy cooler temperature was maintained.
- Frozen meat was properly thawed out in the refrigerator.
- Prepared leftover foods were properly labeled, dated and stored in the refrigerator or freezer within 30 minutes of being serving.
These failures had the potential to expose all patients, visitors and staff to cross contamination and increased the potential to spread infection.

Review of the hospital's policy, "Food Preparation," dated 06/2024, showed:
- Food would be properly handled to protect patients/residents from contamination.
- Frozen foods, such as meat, would be thawed in the refrigerator, not at room temperature.
- Foods would be stored in the refrigerator in a shallow, covered container, labeled and dated.
- Pre-portioned desserts, salads, meats, sandwiches and cold foods would be stored in the refrigerator at 41 degrees Fahrenheit or lower until served.

Review of the hospital's policy titled, "Tray Audits," dated 06/2024, showed:
- Tray audits were performed to ensure safe food temperatures and infection control standards.
- The dietitian or designee should perform at least one test tray audit weekly.
- Cold foods were maintained at a temperature of 41 degrees F or less and hot foods were maintained at a temperature of 140 degree or greater.

Review of the hospital's policy titled, "Cleaning Procedures, Dietary 10.3.2," revised on 06/2024 showed the nutrition service manager was to assign the responsibility of cleaning duties to kitchen staff and monitor compliance with the cleaning schedule. Staff were to clean and sanitize all workstations with an approved detergent and sanitizer, at a minimum of every four hours, or more frequently when needed.

Review of the hospital's policy titled, "Food Storage," dated 06/2024, showed:
- Food was stored in sealed containers, at appropriate temperatures to maximize shelf life.
- Broken lots of bulk staples were stored in containers with tight fitting covers.
- Kitchen staff should inspect the cleanliness of the area on a regular basis. Inspect the food storage area for bulging or broken containers, for spilled, spoiled or infected food, keeping the area clean and organized. Any spilled, spoiled or infected food should be immediately removed, and the area thoroughly cleaned.
- The nutritional service manager should ensure that refrigeration units maintain a temperature at 34 to 40 degrees F.

During concurrent observation and interview on 04/15/25 at 2:15 PM, with Staff T, Kitchen Supervisor and Staff S, Operations Manager, in the cafeteria and kitchen, showed:
- The cafeteria's milk cooler, contained 31 boxes of expired apple juice. Staff S stated that Hyland dairy staff check the cooler when they make deliveries. He was unaware if any other staff checked the coolers for expired product. He depended on Hyland dairy delivery staff.
- One pack of opened flour tortillas on the countertop without an opened date or expiration date.
- A large plastic container labeled parfait toppings that contained a large jug of Smucker's raspberry syrup, one large jug of chocolate syrup, one plastic container labeled Heath bar, one plastic container labeled coconut, one plastic container labeled granola, one plastic container of M & M candy and one plastic container of chocolate chips on the counter. None of the containers were labeled with an opened or expiration date. The containers were dirty and had dried syrup on their exteriors.
- One opened loaf of bread without an opened or expiration date.
- Three individual sized cartons of soy milk that were warm to touch. Staff T stated they needed to be placed back into the cooler. She was unaware of how long they had been sitting out, so they should be discarded.
- On the counter by the large stove, there was a large box that contained 20 closed boxes of baking soda and one opened box. It had a large water like stain on 75% of the large box. There was one opened box of baking soda that had spilled out inside the on top of the other boxes of baking soda that was dried on the boxes. The opened baking soda was without an opened date or expiration date.
- Multiple containers of seasonings and dry goods located on a shelf near the stove. One large plastic container of oregano seasoning dated 11/16, an undated open taco seasoning box, one undated open box of country gravy mix, one undated open box of corn starch, two undated opened boxes of spaghetti noodles, one undated open box of pancake mix, and one unlabeled open box of brown sugar.
- Two fryers containing dark brown grease, with lots of sediment within in them. The exterior of both fryers was covered in dried grease. Staff S stated that the grease was changed every two weeks and that the fryers were to be cleaned daily. Staff T agreed that the fryers appeared dirty and looked like they were not cleaned on a regular basis.
- Located above the stove were undated, open containers of cinnamon, soy sauce, steak seasoning, and garden seasoning.
- The freezer contained unlabeled, open bags of chicken nuggets and chicken patties laying on a shelf. The individual chicken patties were covered with an iced coating.
- The cooler contained unlabeled, open bags of hamburger buns, hot dog buns, garlic bread, cookies, brownies, muffins, and plastic bags of vegetarian chicken, dated 1/25, with an iced coating on the patties. Staff T was unaware of how long the open vegetarian chicken could be stored in the plastic bags.
- The fruit and vegetable cooler contained unlabeled, open boxes of celery, lettuce, tomatoes, and a plastic container of crushed berries.
- The dairy cooler contained unlabeled, opened bundle of plastic wrapped sliced American cheese, an open jug of lime juice, two undated, open packages of sliced provolone cheese, an open, expired tub of blue cheese, four expired individual packs of sugar-free Jello, and two unlabeled, open jugs of barbeque sauce.
- The meat and egg cooler contained an open, expired package of bologna, dated 03/18/25, an undated, open carton of Almond milk, an undated, open jug of liquid eggs and an open carton of soy milk without a lid, which leaked onto the cooler floor. The milk was no longer liquid but was a sticky film which covered the majority of the cooler floor.
- Shelves outside of the coolers contained four boxes of frozen pork chops being thawed at room temperature. Staff T was unaware guidelines for thawing frozen meats. She did not know how long the pork chops had been sitting out to thaw. Staff routinely thaw frozen meats for the next meal outside of the coolers.
- The dairy cooler did not have a functional thermostat, and temperatures were not being monitored.

During an interview on 04/15/25 at 2:15 PM, Staff T, Kitchen Supervisor, stated that boxes and packages of food were to be labeled with the date they were received from the supplier and the manufacturer's expiration date. The hospital did not have a standardized protocol directing staff on how to label food items once they were removed from their original boxes or packages. Refrigerated, multi-serving foods and drinks expired five days after they were opened. She did not know how kitchen staff would be aware the opened or expiration dates. There was no guidance on how items were to be labeled once opened. Kitchen staff were required to obtain food handlers certification. Her certification had been expired for several years. No one monitored staff certification.

Review of the hospital document titled, "Nutrition Department Master Cleaning Schedule," showed all equipment, counters, dishes, and pots and pans were to be cleaned on a daily basis and checked off. Documents for the months of January 2025, February 2025, March 2025, and the current month of April 2025, were blank, indicating that cleaning was not completed.
During an interview on 04/15/25 at 4:30 PM, Staff S, Operations Manager, stated that he recently became the manager. He was unaware that the daily cleaning checks for equipment and workstations had not been completed for four months, that staff were required to have food handler certification, or which staff members had current certification. He did not know the policy for labeling and dating opened food items. The fryer grease was supposed to be changed out every two weeks, but the staff member that had been doing that quit his job. None of the other staff knew how to change out the grease. He was unaware that the freezer did not have a temperature gauge on it.

Review of the hospital's policy, "Standard Precautions," dated 04/2024, showed
hand hygiene was the best way to prevent the spread of infection and should be performed before and after every patient contact. All surfaces and reusable equipment should be properly cleaned utilizing hospital-grade disinfectant cleaners prior to use on another patient.

Observation on 04/14/25 at 2:35 PM, Three North, showed Staff Z, RN, place Patient #7 in the seclusion room for disruptive behavior. She then obtained an order for an as needed medication, removed a Thorazine 50 mg vial from the medication dispensing cabinet, and place it on the countertop of the nursing station desk. Staff Z withdrew the medication from the vial using a syringe, placed the syringe on the countertop of the nursing station desk, applied gloves and administer the medication to Patient #7. Staff Z failed to perform hand hygiene after her initial contact with Patient #7, prior to removing the medication from the medication dispensing cabinet, or before applying gloves for administration.

Observation on 04/15/25 at 8:08 AM, Three North, showed Staff Z, RN, failed to perform hand hygiene prior to removing medication from the medication dispensing cabinet for Patient #12. She prepared the medication on the countertop of the nursing station desk, without cleaning the surface. Staff Z obtained a glass of water from the sink and placed the medication and water on the countertop. She then administered the medication to Patient #12. Hand hygiene was not performed prior to the administration of the medication.

Observation on 04/15/25 at 8:12 AM, Three North, showed Staff Z, RN, did not perform hand hygiene prior to obtaining medication from the medication dispensing cabinet for Patient #20. She prepared the medication on the countertop of the nursing station desk, without cleaning the surface. Staff Z obtained a glass of water from the sink and placed the medication and water on the countertop. She then administered the medication to Patient #20. Hand hygiene was not performed prior to administration of the medication.

Observation on 04/15/25 at 8:15 AM, Three North, showed Staff Z, RN, did not perform hand hygiene prior to obtaining medication from the medication dispensing cabinet for Patient #37. She prepared the medication on the countertop of the nursing station desk, without cleaning the surface. Staff Z obtained a glass of water from the sink and placed the medication and water on the countertop. She then administered the medication to Patient #37. Hand hygiene was not performed prior to administration of the medication.

Observation on 04/15/25 at 8:19 AM, Three North, showed Staff Z, RN, did not perform hand hygiene prior to obtaining medication from the medication dispensing cabinet for Patient #6. She prepared the medication on the countertop of the nursing station desk, without cleaning the surface. Staff Z obtained a glass of water from the sink and placed the medication and water on the countertop. She then administered the medication to Patient #6. Hand hygiene was not performed prior to administration of the medication.

Observation on 04/15/25 at 8:26 AM, Three North, showed Staff Z, RN, did not perform hand hygiene prior to obtaining medication from the medication dispensing cabinet for Patient #7. She prepared the medication on the countertop of the nursing station desk, without cleaning the surface. Staff Z obtained a glass of water from the sink and placed the medication and water on the countertop. She then administered the medication to Patient #7. Hand hygiene was not performed prior to administration of the medication.

Observation on 04/15/25 at 8:32 AM, Three North, showed Staff Z, RN, did not perform hand hygiene prior to obtaining medication from the medication dispensing cabinet for Patient #8. She prepared the medication on the countertop of the nursing station desk, without cleaning the surface. Staff Z obtained a glass of water from the sink and placed the medication and water on the countertop. She then administered the medication to Patient #8. Hand hygiene was not performed prior to administration of the medication.

Observation on 04/15/25 at 8:35 AM, Three North, showed Staff Z, RN, did not perform hand hygiene prior to obtaining medication from the medication dispensing cabinet for Patient #38. She prepared the medication on the countertop of the nursing station desk, without cleaning the surface. Staff Z obtained a glass of water from the sink and placed the medication and water on the countertop. She then administered the medication to Patient #38. Hand hygiene was not performed prior to administration of the medication.

Observation on 04/15/25 at 8:37 AM, Three North, showed Staff Z, RN, did not perform hand hygiene prior to obtaining medication from the medication dispensing cabinet for Patient #39. She prepared the medication on the countertop of the nursing station desk, without cleaning the surface. Staff Z obtained a glass of water from the sink and placed the medication and water on the countertop. She then administered the medication to Patient #39. Hand hygiene was not performed prior to administration of the medication.

Observation on 04/15/25 at 8:40 AM, Three North, showed Staff Z, RN, did not perform hand hygiene prior to obtaining medication from the medication dispensing cabinet for Patient #40. She prepared the medication on the countertop of the nursing station desk, without cleaning the surface. Staff Z obtained a glass of water from the sink and placed the medication and water on the countertop. She then administered the medication to Patient #40. Hand hygiene was not performed prior to administration of the medication.

Observation on 04/15/25 at 8:42 AM, Three North, showed Staff AA, RN, did not perform hand hygiene prior to obtaining medication from the medication dispensing cabinet for Patient #9. She prepared the medication on the top of the WOW at the nurse's station, without cleaning the surface. Staff AA obtained a glass of water from the sink and placed the medication and water on the countertop of the medication window. She then administered the medication to Patient #9. Hand hygiene was not performed prior to administration of the medication.

Observation on 04/15/25 at 8:44 AM, Three North, showed Staff AA, RN, did not perform hand hygiene prior to obtaining medication from the medication dispensing cabinet for Patient #10. She prepared the medication on the top of the WOW at the nurse's station, without cleaning the surface. Staff AA obtained a glass of water from the sink and placed the medication and water on the countertop of the medication window. She then administered the medication to Patient #10. Hand hygiene was not performed prior to administration of the medication.

Observation on 04/15/25 at 8:49 AM, Three North, showed Staff AA, RN, did not perform hand hygiene prior to obtaining medication from the medication dispensing cabinet for Patient #11. She prepared the medication on the top of the WOW at the nurse's station, without cleaning the surface. Staff AA obtained a glass of water from the sink and placed the medication and water on the countertop of the medication window. She then administered the medication to Patient #11. Hand hygiene was not performed prior to administration of the medication.

During a concurrent interview and observation on 04/15/25 at 9:25 AM, Four South, showed Staff I, RN, obtained pain medication for Patient #4 from the medication dispensing cabinet and placed it on the medication cart surface, without cleaning the surface. She proceeded to transport the medication cart from the nursing station into Patient #4's room to administer the medications. Patient #4 was restricted to her room due to vomiting. Hand hygiene was not performed prior to entering Patient #4's room. After administering the medication, Staff I exited the room with the medication cart without performing hand hygiene. She returned the medication cart to the nursing station without cleaning the surface. Staff I stated that hand hygiene was to be performed before and after, any patient contact. The medication carts and other muti-patient use equipment was cleaned, once a shift or when needed.

Observation on 04/16/25 at 8:20 AM, Four North, showed, Staff O, RN, removed Patient #13's medication from the medication dispensing cabinet and placed it on the medication cart surface, without cleaning the surface. She proceeded to transport the medication cart to the patient and administered the medication. After administering the medication, Staff O returned the medication cart to the nurse's station without cleaning the surface.

During an interview on 04/16/25 at 1:00 PM, Staff R, Infection Control RN, stated that, hand hygiene was to be performed before and after, each patient contact. When a medication cart was taken into a patient's room, the nurse was expected to sanitize the cart's surface afterwards, per policy. All surfaces were to be cleaned prior to placing medications on top of them. The countertops and medication window surface should be cleaned after each patient.

During an interview on 04/17/25, Staff CC, Director of Nursing (DON), stated his expectation was for staff to follow policy on hand hygiene and cleaning surfaces in between all patient care.