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Based upon observation, interview, and record review the facility failed to provide and maintain adequate physical facilities for the safety and needs all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include

A-0701 - Failure to maintain the physical environment
A-0710 - Failure to comply with applicable provisions of the 2012 edition of the Life Safety Code
A-0724 - Failure to provide preventative maintenance and upkeep
A-0726 - Failure to ensure proper ventilation and temperature control

Based on observation, interview, and document review, the hospital did not maintain the condition of the physical facilities adequately to ensure patient safety resulting in the risk a harm to all occupants, including all 45 inpatients.

Based on observation, interview, and document review, the hospital did not maintain the condition of the physical facilities adequately to ensure patient safety resulting in the risk a harm to all occupants, including all 45 inpatients.

1. On January 7, 2021 at approximately 1036 observed an unsecured oxygen E cylinder in the medication room on 7th floor south wing. Should the cylinder fall over, the stem could break off creating a lethal projectile. This was confirmed by Staff A at the time of observation.

2. On January 7, 2021 at 1040 observed that a door latch had been taped over on the medication room door on 7th floor south wing so that the room could not be kept locked. This was confirmed by staff A at the time of observation.

3. On January 7, 2021 at 1050 observed that a crash cart tamper tag was broken and staff C commented that she did not know it was broken. At this time review of the crash cart inspection log revealed that it had been inspected the day before, but no inspection had yet been done on 1/7/21. Thus, the facility could not be assured that the contents of the cart were complete and intact. This was confirmed with Staff C at this time.

4. On January 11, 2021 at approximately 1440 observed a deteriorated water damaged sink backsplash in the Central Processing area. It was swollen and warped so that it was coming away from the wall. Upon disturbing the backsplash a centipede crawled out from behind it. This was confirmed by Staff B & D at the time of observation.

Based upon observation, interview and record review the facility failed to provide and maintain adequate physical facilities for the safety and needs of all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include

See the individually and below cited K-tags dated January 07, 2021.
K-0223
K-0324
K-0343
K-0345
K-0353
K-0711
K-0791
K-9999

Based upon observation, interview and document review, the facility failed to provide and document adequate preventive maintenance and building upkeep resulting in potential for building, infrastructure and equipment failures which could result in serious harm to all 45 patients.

1. On January 7, 2021 at approximately 1345 observed a toilet in Room 317 on 3 South leaking at the base onto the floor after flushing. This was confirmed by Staff B at the time of observation.

2. On January 7, 2021 at approximately 1440 in the 2nd floor South mechanical room observed that the pre-filters in AHU-2 were dirty and some were caving in. The filters were last changed on 7-21-2020 according to log sheet attached to the air handler. The damaged air filters were allowing unfiltered air to bypass past the pre-filters which could allow dirt to start clogging the heating or cooling coils and provide an environment for mold growth. This was confirmed by Staff B at the time of observation.

3. On January 11, 2021 at approximately 1033 in the Powerhouse observed a floor stain approximately 20 square feet size. Staff E explained that the stain was from a leak that was in the roof right above the generator.

4. On January 11, 2021 at approximately 1219 during document review of the emergency generator maintenance monthly preventative maintenance (PM) logs for November and December 2020, revealed that there was no record of electrolyte specific gravity testing for the generator starting batteries. Staff B confirmed that this test was not being done at the time of review.

5. On January 11, 2021 at approximately 1246 requested from Staff B documentation of the 4 hour emergency generator run test under connected load that is required every three years, but this was not provided and there is no record of this test ever being done. Staff B explained that the facility had not yet contracted with their generator service company to provide this service to comply with the new NFPA requirement.

6. On January 11, 2021 at approximately 1440 PM requested to see record of any preventive maintenance testing being done to the isolated power Line Isolation Monitors (LIMS) for the operating rooms This information was not provided. At the time of the request, Staff B explained that the facility was not conducting routine preventive maintenance on the LIMS.

Based on observation and interview the facility failed to ensure proper ventilation and temperature controls within the hospital resulting in the potential for harm to all patients. Findings include:

1. On January 7, 2021 at approximately 1211 observed 4th floor South soiled utility room, which is required to have negative pressure, had slight positive pressure relationship with hallway. Staff A confirmed that exhaust fan was not working at the time of observation.

2. On January 7, 2021 at approximately 1425 Patient M, who was standing at the entrance to Room 427, complained to the survey team that his room heating unit was not heating very well. Upon entering the room at that time, observed that the Room 457 heating coil on top of the incremental heating unit was full of dirt and debris. Also observed that the heating coil was warm but not hot. This coil would heat the room more effectively if it were cleaned. This was confirmed by Staff A at the time of the observation.