Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 531311 (X3) Date Survey Completed 09/29/2016
Name of Provider or Supplier Crook County Hospital Street Address, City, State 713 Oak Street, Sundance, WY
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
C0279 PATIENT CARE POLICIES
CFR(s): 485.635(a)(3)(vii)

[The policies include the following:] Procedures that ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices and the orders of the practitioner responsible for the care of the patients, and that the requirement of ยง483.25(i) of this chapter is met with respect to inpatients receiving posthospital SNF care.


This STANDARD is not met as evidenced by:
Based on observation, staff interview, and review of maintenance logs and policy and procedure, the facility failed to ensure sanitary conditions in 1 of 1 kitchens and for 2 of 2 ice machines. In addition, the facility failed to have a nutrition department policy and procedure manual specific to their operation and processes. The findings were: 1. The following concerns were identified related to ice machines: a. Observation of the ice maker/dispenser in the kitchen on 9/28/16 at 9:30 AM showed the plastic part where the ice came out was corroded with white/cream colored substance that appeared to be hard water mineral build-up. The interior of the machine where the ice was made also had large areas of what appeared to be hard water mineral build-up. b. Observation on 9/28/16 at 9:50 AM showed the ice machine located near the nurses' station had hard water build-up on the exterior sides located around the rubber seal. The seal appeared to be in poor condition allowing seeping from the interior. c. Interview with the maintenance assistant on 9/28/16 at 9:50 AM verified the build-up on both machines was from the hard water. Review of the maintenance logs showed the machines were cleaned and sanitized every 3 months. The last time the machines were cleaned was 6/30/16, and they were due. The maintenance assistant verified some parts may need to be replaced if they were unable to be effectively cleaned; however, there was no planned time frame to replace the worn parts. 2. Observation in the kitchen on 9/28/16 at 9:30 AM showed the vents of the hood system were soiled with dark dust and grease. There were two hand sinks in the kitchen and both had unlabeled nail brushes available for use. Three cutting boards stored on a shelf had deep scoring which made the surface no longer cleanable. Interview with the dietary manager at that time verified the cutting boards were old and in poor condition. She further revealed the hood vents were cleaned every 6 months when the contracted professionals came to service the hoods. Further, the manager was not aware it was unacceptable to share nail brushes. According to Food Code 2013, U.S. Public Health Service, Annex 3- Public Health Reasons / Administrative Guidelines: 2-301.12 Cleaning Procedure. "...Fingernail brushes, if used properly, have been found to be effective tools in decontaminating this area of the hand. Proper use of single-use fingernail brushes, or designated individual fingernail brushes for each employee, during the handwashing procedure can achieve up to a 5-log reduction in microorganisms on the hands." According to Food Code 2013, U.S. Public Health Service: 4-601.11 "(A) Equipment food-contact surfaces and utensils shall be clean to sight and touch...(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris." According to Food Code 2013, U.S. Public Health Service: 4-201.11 "EQUIPMENT and UTENSILS shall be designed and constructed to be durable and to retain their characteristic qualities under normal use conditions. 3. Review of the dietary and nutrition department policy manual showed it was a purchased policy and procedure manual. There had been no revisions or facility specific procedures developed or any reviewed dates. Interview with the consultant registered dietitian on 9/29/16 at 11 AM revealed the policy manual needed to be reviewed and procedures could be tailored to fit the process used at the hospital.