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Based on observation, staff interviews, and review of maintenance documents, the facility did not maintain the building systems to ensure a safe physical environment. These deficiencies occurred in all of the 36 smoke compartments, and would affect all patients in the facility on the day of the survey, as well as staff and visitors.

The cumulative effect of these deficiencies resulted in the hospital's inability to ensure a safe and clean environment for all patients.

Findings include:
On September 1, 2010 surveyor #18107 observed that the facility had the following deficiencies: K12 (building type), K18 (corridor doors), K25 (smoke barrier walls), K27 (smoke barrier doors), K29 (hazardous rooms), K38 (egress), K45 (redundant lighting), and K56 (sprinklers). Refer to the full description of the deficient practice at the cited K-tags.

On tour of the hospital September 1, 2010 from 9 AM till 6 PM and document paper review the next day September 2, 2010 until 1 PM, observations and validations from staff interviews, reflect the hospital failed to maintain a safe and sanitary environment for all patients. See A701, A709 and A726 and A749 for details.

Based on staff interviews, observations, and review of standards of practice, the facility did not maintain the condition of the physical plant and overall hospital environment in a manner to ensure a safe environment. This deficiency occurred in all of the 36 smoke compartments, all inpatient units, and would affect all patients in the facility on the day of the survey and follow-up verification visit, as well as staff and visitors.

The following deficiencies are re-cites due to correction dates on previously approved plans of correction actions, not yet expired.

Findings include:
By Surveyor #18107:
Tour by Surveyor #18107 on September 1, 2010 at 9:00 AM through 6:00 PM with Staff CC (Mech.Util. Engr.), Staff DD (Oper. & Maint. Sprvsr.) and Staff EE (Associate Dir. - Operations), and follow-up pictures for document review on September 2, 2010 confirming some cites corrected on September 1, 2010. The following cites verified the following deficiencies have not been corrected and remain non-compliant from original re-certification survey of May 11, 2010. Corrective action plans with approved completion dates have not expired.

1. In the 1st and every other floor in the occupied spaces, carpet flooring was damaged or ceramic tile and base was missing and in need of repair in the following areas:
31-A: #1045-Conference Room (carpeting);
42-B: in the Maintenance Toilet Room (ceramic tile and base);
43-H1:in #3-04A-Women's Locker Room (carpeting); and
53-C: in #3306A-Staff Locker Room (carpeting)

2. In the 22-N smoke compartment on the 2nd floor, the Atrium Exterior Wall had a portion of a wall damaged and in need of repair. The exterior brick veneer was pulling away from the window sill at the upper story of the atrium space. The damage is about 10 lineal feet and the crack is between 3 to 4 inches wide. Brick veneer is dangling on the window sill edge.

3. In the smoke compartment on the 1st floor, in the occupied space, walls were damaged and in need of repair in the following area:
31-A; in #1044-Housekeeping Room.

4. In the smoke compartment on the 1st and every other floor in the occupied areas, walls were damaged and in need of repair. Damaged walls showed evidence of the growth of black mold. (See A749 for reference to Standards of Practice regarding infection control and mold):
31-B:in the Janitor Closet;
42-B: in #3-Janitor Closet;
43-D1: in #3-Janitor Closet;
43-H1:in #3206-Housekeeping Room;
43-H1:in Housekeeping Room #3206;
53-A1: in #3-Janitor Closet;
53-B1: in #3-Janitor Closet;
53-CC: in #3309-Housekeeping Closet

5. In the 52-A2 smoke compartment on the 2nd floor, in the #2336-Acute Clothing Room, a portion of the wall was damaged and in need of repair. The east and south walls had vertical stains in numerous locations due to seepage of water from leaks in the foundation wall. Towels were dispersed around the perimeter of room to soak-up the water along the exterior walls. This room is used for storage of linens.

Based on observation, staff interviews and review of maintenance records, the facility did not construct, install and maintain the building systems to ensure a life safety environment in the building to meet the minimum requirements of the 2000 Edition of the Life Safety Code for the "Existing Healthcare Occupancy" chapters. This deficiency occurred in all of the 36 smoke compartments, and would affect all patients in the facility on the day of the survey, as well as staff and visitors.

The following deficiencies are recites due to correction dates on previously approved plans of correction actions not yet expired.

Findings include:
On September 1, 2010 surveyor #18107 observed via verification visit tour and documentation reviewed in a meeting prior to tour with hospital facility staff, that the facility had the following life safety deficiencies: K12 (building type), K18 (corridor doors), K25 (smoke barrier walls), K27 (smoke barrier doors), K29 (hazardous rooms), K38 (egress), K45 (redundant lighting), and K56 (sprinklers). Please refer to the full description of the deficient practice at the cited K-tags.

Based on observation, review of maintence records, and staff interviews, the facility failed to have a ventilation system that was installed and properly maintained. This deficiency occurred in all of the 36 smoke compartments, and would affect all patients in the facility on the day of the verification visit, as well as staff and visitors.

The following deficiency is a re-cite due to the correction dates on previously approved plans of correction actions not yet expired.

Findings include:
Verified through interview, documentation review and confirmed by Staff CC, Staff DD and Staff EE via verification visit tour on 9/1/2010 from 9 am until 6 pm, the final balancing report available, showed many areas (rooms) within the hospital are outside the 10% tolerance for supply and return air. Thereby not meeting the minimum air requirements per the building codes enforced at the time of the construction.

Based on observation and staff interview, and standards of practice, the hospital failed to ensure a sanitary environment. Environmental tours reflect one of two freezers observed in the off-site kitchen have not been repaired. This is a re-cite due to correction dates on previously approved plans of correction actions not yet expired.

Findings include:
According to the 2007 Guidelines for Isolation Precaution: Preventing Transmission of Infectious Agents in Healthcare Settings, the following standards apply to hospitals:

11.1 Environmental measures. " Cleaning and disinfecting, non-critical surfaces in patient-care areas are part of standard precautions. The cleaning and disinfection of all patient-care areas is important for frequently touched surfaces, especially those closest to the patient, that are most likely to be contaminated (e.g., bedrails, bedside tables, commodes, doorknobs, sinks, surfaces and equipment in close proximity to the patient) " . " In all healthcare settings, administrative, staffing and scheduling activities should prioritize the proper cleaning and disinfection of surfaces that could be implicated in transmission " .

CDC, Facts about Stachybotrys chartarum and Other Mold: " What are the potential health effects of mold in buildings and homes? " Some people are sensitive to molds. " These people may experience symptoms such as nasal stuffiness, eye irritation, wheezing, or skin irritation when exposed to molds " . "Immunocompromised persons and persons with chronic lung diseases like COPD are at increased risk for opportunistic infections and may develop fungal infections in their lungs " .

VI.C.2. Of the 2007 Guideline for Isolation Precaution: Preventing Transmission of Infectious agents in Healthcare Settings. " Lower dust levels by using smooth, nonporous surfaces and finishes that can be scrubbed, rather than textured material (e.g., upholstery). Wet dust horizontal surfaces whenever dust detected and routinely clean crevices and sprinkler heads where dust may accumulate " .

FDA 2005 FOOD CODE- U. S. Department of Health and Human Services

6-201.11 Floors, Walls, and Ceilings. Except as specified under ? 6-201.14 and except for antislip floor coverings or applications that may be used for safety reasons, floors, floor coverings, walls, wall coverings, and ceilings shall be
designed, constructed, and installed so they are SMOOTH and EASILY CLEANABLE.
6-201.12

6-501.11 Repairing.
PHYSICAL FACILITIES shall be maintained in good repair. 6-501.12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. (B) Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least
amount of FOOD is exposed such as after closing.

4-202.11 Food-Contact Surfaces. (A) Multiuse FOOD-CONTACT SURFACES shall be: (1) SMOOTH; (2) Free of breaks, open seams, cracks, chips, inclusions,
pits, and similar imperfections; (3) Free of sharp internal angles, corners, and crevices; (4) Finished to have SMOOTH welds and joints.

4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications.

During a tour on 6/28/10 at 9:45 a.m. accompanied by Assistant Administrator H and Aviands Lead O, (contracted service), it was noted that in the Off Site Kitchen, on the second floor, Freezer #2 has cracked floors and rusting walls and ceiling noted by chipping metal and exposed rust rendering it unable to be effectively cleaned.

Aviands Lead O confirmed in interview, that these surfaces could not be repaired by the time of the re-visit and the facility awaits parts and quotes to repair the freezer. This finding was discussed and confirmed with Acute Inpatient Director A on 6/30/10 at 10:05 a.m. via telephone call.

This deficiency remains out of compliance as of 9/02/2010.