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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 3 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 March 1, 2011 as part of a quarterly verification visit, surveyor #18107 observed that the facility had the following deficiencies: K29 (hazardous rooms) and K45 (redundant lighting). Refer to the full description of the deficient practice at the cited K-tags.

On tour of the hospital March 1, 2011 from 9:20 AM till 12:30 PM and document paper review the next day March 2, 2011 until 1 PM, photo observations and validations from staff interviews, reflect the hospital failed to maintain a safe and sanitary environment for all patients. See A701 (maintenance of physical plant), A709 (life safety from fire) and A749 (infection control) for details.




22219

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 3 smoke compartments, affecting 30 inpatients in the facility on the day of the verification visit follow-up, 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:
Tour by Surveyor #18107 on March 1, 2010 at 10:00 AM to 12:30 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 back in the office on March 2, 2011 confirming some cites corrected on March 1, 2011. The following cite verified the following deficiency had 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 (Due: 06/01/2011).

In the smoke compartment on the 3rd Level in the occupied area (Building 5), the wall in corridor near the smoke barrier, was damaged and in need of repair. Damaged wall showed evidence of recent contact with a heavy motorized mobile food cart, puncturing into wall exposing dust and dirt onto the floor and adjoining wall. Wall was not fixed before exiting site. (See A749 for reference to Standards of Practice regarding infection control): Near 53-B.


22219

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 3 smoke compartments, and would affect 30 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 (Due: 06/01/2011).

Findings include:
On March 1, 2011 surveyor #18107 observed via a follow-up verification visit tour and documentation reviewed after the exit meeting with hospital facility staff, that the facility had the following life safety deficiencies: K29 (hazardous room) and K45 (redundant exterior lighting). Please refer to the full description of the deficient practice at the cited K-tags.












22219

26711

Based on observation and staff interview by surveyor 18107, and standards of practice, the hospital failed to ensure a sanitary environment. Environmental tour reflected several counter tops and attached p-lam walls to the counter tops were de-laminating within the kitchen building at 1st and 2nd floors and had not been repaired. This is a re-cite due to correction dates on previously approved plans of correction actions, not yet expired (Due: 06/01/2011).

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.

Findings (Continued):
1. Surveyor 18107 observed on 12/06/2010 while touring with Staff CC, DD & EE in the late afternoon, several 'counters' in the food preparation and storage areas at both 1st and 2nd Levels of the Kitchen Building were found to be de-laminating. This presents the potential for growth of bacteria in those porous areas of these counters where food is present. After talking with staff in interview, these counters had not been removed or resealed as yet. They stated they will be completed with rest of deficient cites before 06/01/2011.

2. Surveyor 18107 observed on 03/01/2011 while touring with Staff CC, DD & EE in the morning near 12-Noon, the corridor wall was damaged by a motorized meal cart. The wall was porous and exposed with dust and dirt particles present on the floor and on wall around the damaged area. This presents the potential for growth of bacteria in those porous areas. The wall was not fixed before the surveyor exited the building.