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 673078 (X3) Date Survey Completed 01/25/2022
Name of Provider or Supplier Shannon Rehabilitation Hospital, An Affiliate Of E Street Address, City, State 6046 Appaloosa Trail, San Angelo, TX
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)
A0620 DIRECTOR OF DIETARY SERVICES
CFR(s): 482.28(a)(1)

The hospital must have a full-time employee who- (i) Serves as director of the food and dietetic services; (ii) Is responsible for daily management of the dietary services; and (iii) Is qualified by experience or training.


This STANDARD is not met as evidenced by:
Based on observation, interview, and record review, the facility's Director of food and dietetic services failed to provide dietary services in a sanitary environment, when moldy and out of date foods were available for use, the kitchen's food preparation surfaces had old food debris present, food items were not labeled or dated when opened, and the facility was not storing or holding cooked foods to prevent spoilage. These practices place all patients at risk for food borne illnesses resulting in gastrointestinal pain, nausea/vomiting, diarrhea, dehydration and possibly death. Findings include: Review of the facility provided policy Food Handling and Preparation Policy# 302, (dated 7/9/2021) reflected: "PURPOSE To ensure the highest level of quality food service by safe, sanitary procedures. RESPONSIBILITY The Nutrition Manager/Director and Management Team ensure these procedures are taught, followed and enforced POLICY All foods shall be handled and prepared in such a manner to ensure their safety and quality, by adhering to the standards and procedures outlined below. They are based on accepted, safe, effective, efficient and sanitary principles. 1. All foods shall be prepared in a sanitary manner, adhering to nutrition principles and presented in an appetizing and attractive fashion ... 4. Maintain all potentially hazardous foods at specified safe temperatures A. Cold foods less than 40 degrees B. Hot foods greater than 140 degrees C. potentially hazardous foods should not be out of safe temperature range for greater than a total of 4 hours, throughout the entire handling/preparation/service process 5. Frozen foods are kept frozen and used within 6 months ... 7. All food preparation surfaces, equipment and hands are thoroughly cleaned, before and after the preparation of each food Product ... 10. Foods are cooked to the proper temperature, according to recipes and/or posted charts. 11. Steam tables and warming cabinets are not to be used to cook or heat food ... 13. Promptly refrigerate unused foods / ingredients and clean up any spillage promptly." Observations made on the morning of 1/21/22, of the facility's dietary department, revealed a 6- quart pot with marinara sauce sitting on the facility's gas burner; the burner was turned off. The sauce had congealed over the top. Staff #3, Dietary Director was asked to take the temperature of the sauce. During an interview, on 1/24/22 in the facility's dietary department, after inserting a thermometer into the marinara sauce, Staff #3, Dietary Director, stated, "It's 98 degrees." The cook was called over to the gas range. During an interview, on 1/24/22 in the facility's dietary department, Staff #4, Cook confirmed she had been cooking the sauce and needed to add to it. When asked what temperature range hot foods can be safely held at, Staff #4 stated, "160 degrees." When asked to see the temperature logs from the previous meal, Staff #3, Dietary Director stated, "They take the temperatures, but we don't record them." Staff #3 was unable to provide a policy and procedure for the recording of food temperatures. During an interview, on the afternoon of 1/24/22, in the facility conference room, Staff #12, Infection Control Preventionist, stated, "I inspect the kitchen ...I have had repeat findings." When asked who he takes the findings to, Staff #12 stated, "I tell Staff #3, Dietary Director ...When I ask for the temperature logs, they have been giving me something." When informed the Staff #3, Dietary Director had stated they do not record the temperatures, Staff #12 stated, "Maybe it's the equipment logs." Further observations in the Dietary department revealed the following: Overripe bananas Stained tea glasses Rust and food debris in two utensil drawers Food debris on the can opener blade Unlabeled/dated bag of sausage patties Frozen foods had been removed from the boxes, not labeled as to what they are or when they arrived to allow for proper rotation A jar of pickle relish was not labeled or dated and had a metal spoon sitting in the jar Food bases were not labeled when opened, and one large container with beef base was not labeled/dated Fruit cocktail was 2 days past expiration, pudding and tuna salad were 6 days past their expiration and available for use 4 celery stalks were wilted and soggy, and over 50 jalapeno peppers were shriveled and partially molded and available for use A cardboard box, containing 25 ½ pints of 2% milk, were sitting on the walk-in floor A carton of instant mashed potatoes was open, allowing access by insects Three spice shelves had food debris, creating an unsanitary environment At least 21 spices had not been dated when opened Two hot plate holders had food debris present on the inside rim A large food strainer's mesh basket handle had copious amounts of rust, which would come off into the food if used Review of The Texas Food Establishment Rule (TFER), TAC §§228, dated October 11, 2015 reflected, Food and Non-food Contact surfaces Cleanable, Properly Designed, Constructed, and Used "228.104(f) Can openers Environmental Contamination 228.69(a)(1)(A) Food shall be protected from contamination by storing the food in a clean, dry location 228.69(a)(1)(B) Storing the food where it is not exposed to splash, dust, or other contamination 228.69(a)(1)(C) Storing the food at least 15 cm (6 inches) above the floor §228.75 (d)(4) (f) Time/temperature controlled for safety food, hot and cold holding. time/temperature controlled for safety food shall be maintained: §228.73(a)(5) of this title may be held at a temperature of 54 degrees Celsius (130 degrees Fahrenheit) or above; P or (B) 5 degrees Celsius (41 degrees Fahrenheit) or less ..."