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Based on observation, interviews and review of policy and procedure the facility failed to maintain a single pharmacist for the management, oversight of scheduled narcotics, policy input and comprehensive medication management. This deficient practice had the potential to negatively effect the entire facility census of 113 patients.

Findings include:

1. Observation on 09/24/14 revealed the facility nursing staff performing administration of scheduled narcotic medications to patients which were obtained from the facility's locked automatic medication machine.

2. Review of the facility contract between the facility and its consulting pharmacy, Omnicare Pharmacy, with an effective date of 03/01/2010 directed the pharmacy would provide pharmacy products and services to the facility. Schedule 1-A of the contract directed the consultant pharmacist to collaborate, develop, and revise as necessary procedures for the provision of pharmaceutical services and strive to assure that medication and biological are requested, received and administered in a timely manner.

3. Review of an agency policy and procedure entitled Storing and Dispensing of Tramadol (a schedule pain medication) and Controlled medications with a most recent review date of 06/10/14 directed that Tramadol and Schedule III, IV, and V medications were obtained from a different pharmacy, Cardinal Heath under the hospital's DEA license and were managed by the hospital's Chief Operation Officer (CEO) and the director of nursing.

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4. Interview with the consultant pharmacy Staff C on 09/25/14 at 9:43 A.M. revealed he/she was on site at the facility once per month. Staff C verbalized that scheduled narcotic medications including Tramadol were procured from a different pharmaceutical source and that Omni Care Pharmacy had no involvement with the monitoring of these scheduled narcotics for pharmacy oversight.

Staff C further verbalized that he/she was not a participant in policy and procedure development or revisions for the facility.

5. Interview with Staff B on 09/25/14 at 10:43 A.M. confirmed the facility had a separate agreement for the management of narcotics and that OmniCare was not involved in the oversight of narcotic medications.

6. Staff C provided a copy of correspondence with an effective date of 08/15/14 that Ashtabula County Medical Center would provide narcotic oversight to the facility.

Based on observation, staff interview and policy and procedure review the facility failed to discard expired food products and provide accessible hand-washing supplies. This deficient practice had the potential to negatively effect the entire census of 113 patients who were served meals from the dietary department. The food service served approximately 339 meals daily for the above census of 113.

Findings include:

Tour on 09/25/14 from 10:43 A.M. until 11:18 A.M. of the hospital's dietary service revealed two of two hand washing stations located near the two main entrances to the dietary department were not supplied with paper towels for use during hand-washing. Staff A indicated staff are to use a roll of paper towels located across the room from the hand-washing station and located on a top shelf over a flat work surface at one hand-washing station only.

Tour of the facility's walk in cooler revealed multiple expired food products which included, a large tray of greater than 12 baked potatoes, the plastic over wrap indicated these potatoes were prepared on 09/18/14, additionally, the cooler contained a fourth of a half gallon plastic jug of chocolate milk which bore the manufacturer's sell by date of 9/15/24, as well as a half gallon jug of prepared orange drink which contained the expiration date of 05/21/14. Examination of the cooler's shelves revealed three 48 ounce blocks of cream cheese which were packaged on 05/31/14. The facility's reach in refrigerator in the kitchen revealed the presence of three six ounce containers of strawberry yogurt with a manufacturer's expiration date of 05/31/14. The dry food storage shelves were observed on 09/25/14 at 11:11 A.M. to contain greater than 24 7.25 ounce cans of chicken soup which contained the manufacturer's expiration date of 12/04/13.

Review of the facility's policy and procedure entitled Proper Food Handling with most recent review date of 09/20/14 directed that foods have a date of three days prior will be discarded. Food with an expired expiration date will be discarded.

Interview with Staff A confirmed all foods prepared by the dietary service were discarded three days after preparation. Staff A confirmed the manufacturer of the cream cheese directed the cream cheese was good for three months after the package date or 08/31/14. Staff A verbalized all staff were responsible to check the coolers, storage areas and refrigerators for outdated or expired foods on an on going basis.

Based on review of facility schematics, facility observation, review of preventative maintenance documentation and staff interview and confirmation, the facility failed to ensure the building was constructed, arranged, and maintained to ensure the safety of the patients. The facility had a capacity of 114 beds with a census of 113 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

The facility failed to ensure that if a building had a common wall with a nonconforming building, the common wall was a fire barrier with at least a two hour fire resistance rating constructed of materials as required for the addition (K11) the smoke barriers were constructed to provide at least ½ hour fire resistance rating (K25), failed to have two light sources at an exit discharge (K45), that the fire alarm system required for the life safety was tested and maintained in accordance with an approved testing and maintenance program in compliance with applicable requirements of NFPA 72 ( K52), the automatic sprinkler system was continuously maintained, inspected and tested periodically (K62).

Based on facility observation, review of facility preventative maintenance documentation and interview and staff confirmation, the facility failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association. The facility had a capacity of 114 beds with a census of 113 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings include:

On 09/24/14 between the hours of 8:45 A.M. and 11:45 A.M. tour of the facility was conducted with Staff T, A and U. Facility observations and review of facility maintenance documentation related to life safety code requirements revealed the following findings:

K11, addressed the facility failure to ensure that if a building had a common wall with a nonconforming building, the common wall was a fire barrier with at least a two hour fire resistance rating constructed of materials as required for the addition.

K25, which addressed the facility failure to ensure the smoke barriers were constructed to provide at least ½ hour fire resistance rating.

K45, which addressed the facility failure to have two light sources at an exit discharge.

K52, which addressed the facility failure to ensure the fire alarm system required for the life safety was tested and maintained in accordance with an approved testing and maintenance program in compliance with applicable requirements of NFPA 72 .

K62, which addressed the facility failure to ensure the automatic sprinkler system was continuously maintained, inspected and tested periodically.

K130, which addressed the facility failure to ensure the exits, other than main exterior exit doors that are obvious and clearly identifiable were marked readily visible from any direction of exit access and failed to ensure emergency illumination was provided in accordance with section 7.9. with regards to testing the emergency lights for 30 seconds per month and 90 minutes annually

Please see the Life Safety Code report for more specific detail.