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Based on observation and interview it was determined that the facility was not maintained in a clean and sanitary environment in that:

A During tour of the Medical-Surgical Unit on 07/30/2025 between 1:00-2:00 Pm it was observed that
1.The call light outside the doors had black substances on the walls in Room 219
2. Room 219 had black substance on air unit and ceiling tiles
3 In room 225 there was residue on the bathroom door, a brown-red stain on the wall, the paint on the walls was bubbling and peeling away and there was a black/grey residue on the vents of the air-conditioning unit.
4 In room 209 there was rust in the tub, black stains on six ceiling tiles, black substance under the light switch, water pooled in the light fixture in the ceiling, and a black/grey residue on the vents of the air-conditioning unit.
5 In room 212 there was water pooling in the overhead light fixture above a patient in bed.
6 Throughout the unit the air-conditioning units had a black/grey buildup on all the vents.
7 There was an odor of wetness throughout the unit
8 The findings in A were confirmed in interview with the Director of Maintenance

The failed practice promoted the spread of infection and had the likelihood to affect all patients in the facility. See A-701.

Based on observation and interview it was determined that the facility was not maintained in a clean and sanitary environment in that:

A During tour of the Medical-Surgical Unit on 07/30/2025 between 1:00-2:00 Pm it was observed that
1 The crash cart had rust on the top and along the edges
2 In the anteroom to rooms 225 and 226 there were dead bugs on the countertop and under the sink.
3 In room 225 there was residue on the bathroom door, a brown-red stain on the wall, the paint on the walls was bubbling and peeling away and there was a black/grey residue on the vents of the air-conditioning unit.
4 In room 209 there was rust in the tub, black stains on six ceiling tiles, black substance under the light switch, water pooled in the light fixture in the ceiling, and a black/grey residue on the vents of the air-conditioning unit.
5 In room 208 a dirty washcloth left in the shower, paint bubbling and peeling by the window and door, water pooling in the overhead light fixture, and a black/grey residue on the vents of the air-conditioning unit.
6 In room 210 there was water flowing from the overhead light fixture on to a chair and the floor and there was a black/grey residue on the vents of the air-conditioning unit.
7 In room 212 there was water pooling in the overhead light fixture above a patient in bed.
8 Throughout the unit the air-conditioning units had a black/grey buildup on all the vents.
9 There was an odor of wetness throughout the unit
6 The findings in A were confirmed in interview with the Pharmacist in Charge and Infection Control Senior Preventionist.

The failed practice promoted the spread of infection and had the likelihood to affect all patients in the facility. See A-750.

Based on review of policy, review of Medication Occurrences, review of Clinical Records and interview, it was determined the Facility failed to assure evidence of medication errors, notification to the practitioner and any interventions the practitioner ordered were recorded, in four (#21, #22, #24 and #25) of six (#20-#26) patient's clinical records reviewed where a medication error occurred. The failed practice did not ensure the clinical record would reflect:
1. exactly what happened in the course of the patient's treatment,
2. medication errors were recorded,
3. notification to the practitioner and
4. any interventions the practitioner ordered after the error.
Also, had these patients needed to be transferred to a higher level of care, their records would not have given the next care providers a clear and accurate picture of these patients' medical history. The failed practice had the likelihood to affect any patients who received a medication error. The findings follow:

A. Record review of the facility's policy titled, "Safety Event Reporting System," approved November 2024, showed when a medication error occurred, documentation in the clinical record should include a description of the event to include what happened, the patient's condition, physician notification, and any interventions ordered.
B. Review of Medication Occurrences for the previous 3 quarters (October 2024- June 2025) showed the following six patient's had medication errors and were reviewed: patient #20 on 10/24/24, patient #21 on 11/17/24, patient #22 on 11/19/24, patient #23 on 12/11/24, #24 on 3/1/25 and patient #25 on 4/4/25.
C. Review of the clinical records showed patients #21, #22, #24 and #25's clinical records did not contain evidence of the medication errors, notification to the practitioner or any interventions the practitioner ordered.
D. During an interview on 07/30/25 at 3:03 PM, the Director of Pharmacy verified the findings at A, B, and C.

Based on observation of the kitchen, emergency department, laundry room., med surgery and interview, it was determined the facility failed to maintain the building physical structure, safety, environment, and equipment in a state of good repair. The failed practice promoted the spread of infection and/or placed the patients at risk of fire. The failed practice had the likelihood to affect all patients, staff and visitors, Finding follow:

A. Observation of the kitchen on 07/28/2025 at 1:25 PM showed rusted and dirty vents in sitting area.
B. Observation of the trauma one in emergency department on 7/28/2025 @ 1:31 PM showed vents needed cleaning.
C. Observation of the Med Surgery on 07/28/2025 @ 1:55 PM a wheelchair was blocking an electrical panel
D. Observation of the Operating Room halls on 07/28/2025 @ 2:24 PM no exhaust fan was functioning correctly
E. Observation of the conference room 2 on 7/28/2025 @ 2:30 PM has water stains on ceiling tiles
F. Observation of the laundry room on 07/29/2025 @ 9:25 AM water stain ceiling tiles all over
G. Observation of hospital on 7/29/2025 @10:00 AM throughout the hospital the peeling of the wall was coming apart
H. The findings A-F were verified by the Director of Maintenance on 07/29/2025 at the time of observation.

Based on observation and interview it was determined that the facility failed to maintain the Labor and Delivery nutrition and supply room in a sanitary manner. This promoted the spreading of infectious material to patient care supplies. The failed practice had the likelihood to affect all patients receiving care in the labor and delivery unit. The failed practice had the likelihood to affect all patients on the Labor and Delivery Unit. Findings follow:

A During tour of the Labor and Delivery Unit on 01/29/2025 at 10:30 AM it was observed that there was a room with both patient nutrition and clean supplies. The clean supplies were in close proximity the coffee maker and trash can. It was observed that there were dark stains on the supplies wall.
B The findings in A were confirmed with the Pharmacist in Charge.


Based on observation and interview it was determined that the facility was not maintained in a clean and sanitary environment. The failed practice did not ensure that the patients in the Medical-Surgical unit were not exposed to potential infectious material. The failed practice had the likelihood to affect all patients receiving care on the Medical-Surgical Unit. Findings follow:

A During tour of the Medical-Surgical Unit on 07/30/2025 between 1:00-2:00 Pm it was observed that
1 The crash cart had rust on the top and along the edges
2 In the anteroom to rooms 225 and 226 there were dead bugs on the countertop and under the sink.
3 In room 225 there was residue on the bathroom door, a brown-red stain on the wall, the paint on the walls was bubbling and peeling away and there was a black/grey residue on the vents of the air-conditioning unit.
4 In room 209 there was rust in the tub, black stains on six ceiling tiles, black substance under the light switch, water pooled in the light fixture in the ceiling, and a black/grey residue on the vents of the air-conditioning unit.
5 In room 208 a dirty washcloth left in the shower, paint bubbling and peeling by the window and door, water pooling in the overhead light fixture, and a black/grey residue on the vents of the air-conditioning unit.
6 In room 210 there was water flowing from the overhead light fixture on to a chair and the floor and there was a black/grey residue on the vents of the air-conditioning unit.
7 In room 212 there was water pooling in the overhead light fixture above a patient in bed.
8 Throughout the unit the air-conditioning units had a black/grey buildup on all the vents.
9 There was an odor of wetness throughout the unit
10 The findings in 1-7 were confirmed in interview with the Pharmacist in Charge and Infection Control Nurse.
11 In Sterile Supply there were corrugated boxes storing items.
12 In Operating Room (OR) #1 there was a used face mask on the anesthesia cart.
13 The doors to OR #1 were worn and bare wood exposed meaning they cannot be disinfected.
14 After the terminal clean none of the equipment was moved to clean supply.
15 During a terminal clean of OR #1 the technician dipped a used cloth into the cleaning solution bucket and reused the same cloth after cleaning the wheels of a gurney and after dusting high surfaces the technician shook the duster in hte room disbursing the dust and debris throughout the OR. Throughout this cleaning mobile surfaces were not relocated to allow sanitzation of the floor under same objects.
16 A stainless steel cart had a plank of rotted wood under it.
17 The findings in 11-16 were confirmed with the Senior Infection Preventionist.