| 52 |
DAMAS HOSPITAL SNF |
405023 |
2213 PONCE BY PASS |
PONCE |
PR |
717 |
2017-05-25 |
371 |
L |
0 |
1 |
NJQB11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a standard and extended FOSS survey for recertification, observation tour at the Kitchen and interview with administrative dietitian (employee #1) Safety Officer (employee #9) and Physical Plant engineer (employee #5) on 5/22, 5/23, 5/24, and 5/25/17 it was determined that the facility failed to prevent patients from harm. This constitutes an Immediate Jeopardy to 9 out of 9 residents (R) admitted at the facility. (R #1 to R#9) Findings include: Observational tour at the Kitchen perform on 5/22/17 at 10:15 am until 12:30 pm, it was found that the facility failed to establish effective infection control precautions to avoid widespread nosocomial infections. The cold storage room is located at the ground floor of this facility. During the observational tour it was found the following: 1. The cold room was found to be out of the temperature range, temperature taken revealed that the cold room was at 75 degree Fahrenheit ( F) 2. The air condition unit of the cold room not functioning and the console did not have cover on with rust and dust that was falling over the counter where the meat is prepared, 3. The vegetable refrigerator had mold around the gaskets and with white mold on the fans 4. A tray of coleslaw and three trays of cantaloupe uncover and without label in front of the refrigerators fans 5. Two refrigerators inside the cold room were filled with mold on the walls and ceilings 6. It was observed that five boxes of 10 pounds of pork chop, five boxes of 10 pounds of turkey, three boxes of 8 pounds of meat, and 8 boxes of 1 pound of chicken were left thawing on the preparing table at 75 'F. The boxes were not label. According to interview with the kitchen staff (Employee #2) on 5/22/17 at 10:30 am, he stated: Those boxes of meats are for production and are to be prepared. The meats were brought early today at 8:30am. They should have been labeled. According to interview with the engineer (employee #5) at 11:45 a.m. he state; Yes I know the situation and we are working on it. It is supposes that for this Friday the air conditioner of the cold room is ready. After that the other air conditioners consoles will be fix it. According to interview with the Dietitian (employee #1), at 10:35 am she state: I reported on this situation since February. Temperatures started to be out of parameters in the Formula room and in the Cold room since February. I have been reporting this situation to the physical plant department and my boss has also mentioned it in the Quality meetings. A Statement of Deficiency was provided to the facility on [DATE] at 2:15 pm notifying the IJ and requesting a Plan of Correction (P[NAME]). The facility provided a P[NAME] on 5/22/17 at 3:30 pm as follow: General instruction and corrective Actions: 1. A portable Air Conditioner will be installed on the Formula Room and the Cold room to reach the adequate temperature 70 degrees. 2. The DL Refrigeration Service Company will provide service to install the covers at the air conditioner console. The labor will be completed on Friday. 3. The vegetable fridge fans will be cleaned immediately by terminal cleaning. 4. Tray of [NAME] slaw and other trays will be cover with Zaron Wrap and labeled with preparation date. 5. The refrigerator and the freezer on the cold room will be cleaned by terminal cleaning including the wall and the ceiling. An onsite visit was performed on 5/23/2017 at 11:15 am to the Kitchen's cold room The P[NAME] was accepted by the surveyors on 5/22/2017 at 3:48 pm. Based on a standard and extended FOSS survey conducted on 5/22, 5/23, 5/24, and 5/25/17 for recertification, the kitchen observational tour, review of official documents and interview with the Nutrition Director (employee #1) and Physical plant director (employee #5), it was determined that the facility failed to ensure a safety place for the store, prepare and serve food under sanitary conditions which can affect 9 of 9 admitted residents (R). (R#1 to R#9) Findings include: 1. During observational tour performed on 5/22/17 at 10:05 am thru 12:05 pm it was found in the following: a. One can of plum of 104 ounces was dent and was located on the active food storage. Was immediately remove by the food storage supervisor (employee #4) b. On the lacteous refrigerator was observed a leak of water that fell on the bottles of milks that were in plastic baskets. The bottles of milks were observed wet. c. On the lacteous refrigerator was observed that boxes of eggs were wet with the splash of the water leak from the refrigerator's air conditioning unit. d. On the bread refrigerator was observed a water leak from the air conditioning unit and water on the floor. The shelves in this refrigerator had rust. e. The air conditioning units from the cold room where not functioning and had not the covers on. It was observed that the facility was using two portable air units that were maintaining a temperature of 75'F. The drainage of the portable air conditioning units was leaking water to the floor. f. It was observed five boxes of 10 pounds of pork chop, five boxes of 10 pounds of turkey, three boxes of 8 pounds of meat, and 8 boxes of 1 pound of chicken that were left on the preparing table inside the boxes at 75'F. The boxes were not label. During interview with the kitchen staff (Employee #2) on 5/22/17 at 10:30 am, he stated: Those boxes of meats are for production and are thawing to be prepared. The meats were brought early today at 8:30am. They should have been labeled. Facility fails to ensure that the regulations establish method to safely thaw frozen food are follow. g. On the second refrigerator of the cold room was observed one tray with 9 Egg beaters of 32 ounces, one of the egg beater box was broken causing a spill of 32 ounces of egg beater all over the tray. h. On the second refrigerator of the cold room was observed a bag of grated cheddar cheese that was opened and without label. i. On the cabinets of the cold room was observed a meat grinder that was uncover, on top of a piece of box, and with white stains. Also, was observed a food crusher that was uncover and on top of a tray that was with dust and white stains. During interview with the kitchen staff (employee #2) on 5/22/17 at 10:45 am, he stated: The meat grinder and the food crusher are not being used. They were cleaned and storage there. j. On cold room was observed that kitchen staff (employee #2) was peeling potatoes from a carton box and inside the box was a partially peal potato with all the pieces of the potato peel. It was observed that right next to the carton box was a tray with uncover vegetables. k. On cold room were observed two carton boxes on top of kitchen materials, the kitchen staff (Employee #2) removed them immediately. The performed a change of gloves and hand wash, however he shake the hands to remove the excess of water and then dried hands with paper. The facility failed to ensure that the kitchen staff performs hand hygiene in accordance with the Centers for Disease Control and Prevention (CDC) Guideline for Hand Hygiene and Glove Use (CDC, 2002) in Healthcare Settings. l. On cold room were observed green and black stains on the floor next to the refrigerators and freezer. m. In the kitchen tour were observed nesting pans, the pans were observed stacked upside down one on top of the other and they were found wet with an accumulation of water. n. On the snack refrigerator was observed bag of American cheese and a bag of turkey jam that were opened and not label. o. On the cabinets use to store the snack food were observed 4 bags of crackers (galletas exporsodas) and 2 bags of vanilla crackers that were not label. p. The refrigerator use to storage the apples, juice box, milks, milk supplements, Jell-O, yogurt, and butter while stoking the line trays was observed on 5/23/17 at 12:15 pm and maintained a temperature of 67degree Fahrenheit ( F). The yogurt internal temperature was measure and showed that it was 65.3 F. However the facility provided evidence that the immediately removed the food from that refrigerator that was expose to high temperatures to prevent residents of potential hazard food. The facility failed to store, maintain, and prepare food in a safe and sanitary manner related to maintaining food at or below 41 F. q. A sample tray was evaluated on 5/23/17 at 11:20 am and showed the following temperatures out of recommended range: (i) Rice: 132.3 F (ii) Turkey: 126.4'F A sample tray was the evaluated on the kitchen on 5/23/17 at 12:00 pm and showed the following temperatures out of recommended range: (i) Rice: 137.4'F (ii) Turkey: 124.4'F The facility failed to store, maintain, and prepare food in a safe and sanitary manner related to maintaining food at hot holding temperature of 135'F to prevent the growth of infectious organisms. |
2020-09-01 |