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Based on observation and interview it was determined the Environmental Services Room, Computed Tomography Room, Emergency Department and Radiology Department was not safe and maintained in a state of cleanliness in that the exhaust fans were dirty and/or nonfunctioning. The failed practice promoted the spread of infection and had the likelihood to affect all patients and staff. Findings follow.

A. Observation of Emergency Room at 1:58 PM on 6/26/23 showed to have dirty exhaust fans.
B. Observation of the Environmental Services Room at 2:00 PM on 6/26/2023 showed to have nonfunctioning exhaust fans.
C. Observation of the Computed Tomography Room at 2:20 PM on 6/26/23 showed to have nonfunctioning exhaust fans.
D. Observation of the storage areas on 6/26/2023 at 1:14 PM showed to have dirty and non-functioning exhaust fans
E. The findings in A-D were verified in an interview with the Maintenance Director on 06/26/2023 at 3:00 PM.



Based on observation of the Radiation Department, Patient Care Areas, Emergency Room , Radiology Department, Computed Tomography (CT) Room Storage Room 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 practices promoted the spread of infection and had he likelihood to affect all patients, staff and visitors. Findings follow:

A. Observation of the Emergency Room, and Radiation Department on 6/26/2023 from 2:00 PM to 2:50 PM showed the following:
1) A black colored substance was present on the ceiling tiles.
2) Brown stained and sagging ceiling tiles were present.
3) Cracked floor tiles.
4) Chipped doors
5) Dirty Air Conditioning vents
6) Damaged Formica on counter tops

B. Observation of the CT Room on 6/26/2023 showed the following:
1) Black colored substance was present on the ceiling tiles.
2) Damaged floor tiles.
3) Missing light covers
4) Penetrations in walls
5) Missing base boards

C. Observation of patient care areas on 6/26/2023 from 10:15 am to 11:23 am showed the following:
1) Black colored substance was present on the ceiling tiles.
2) Brown stained and sagging ceiling tiles were present.
3) The walls had chipped and peeling paint.

D. Observation of storage area near CT Room on 6/26/2023 showed the following:
1) Cracked floor tiles
2) Broken and stained ceiling tiles
3) Damaged and Missing Baseboards
4) penetrations in walls

E. The finding of A, B, C and D were confirmed in an interview with the Maintenance Director on 6/26/2023 at the time of the observations.


Based on observation, review of National Fire Protection Agency (NFPA) requirements, review of policies and procedures and interview, it was determined the facility failed to create and review policies and procedures on a biennial basis for:
1) Ceiling tiles checks
2) Having each emergency receptacle labeled.
3) Annual scheduled electrical panel infrared testing.
4) Fire wall penetration checks
5) Polarity and Tension testing

By not creating and reviewing the policies and procedures biennially, the facility had the likelihood to not be able to identify hazardous conditions and take steps to minimize the risks to patients and patient care staff. The failed practice had the likelihood to affect all patients admitted to the facility. Findings follow:

A. Review of the facility's policy and procedures on 6/26/2023 showed that the facility failed to create and maintain a policy and procedure for scheduling annual Polarity and tension testing and having each emergency receptacle labeled.
B. There was no evidence the facility conducted an annual Polarity and tension testing.
C. Observation on 06/26/23 showed there was no evidence the emergency receptacles were labeled as emergency receptacles.
D. Review of the facility's policy and procedures on 6/26/2023 showed that the facility failed to create and maintain a policy and procedure for conducting annual scheduled electrical Panel infrared testing.
E. There was no evidence the facility conducted an annual electrical panel infrared test.
F. Review of the facility's policy and procedures on 6/26/2023 showed that the facility failed to create and maintain a policy and procedure for conducting monthly scheduled ceiling tile checks.
G. Review of the facility's policy and procedures on 6/26/2023 showed that the facility failed to create and maintain a policy and procedure for conducting scheduled fire wall and penetration checks.
H. Review of NFPA 80, referred by NFPA 1 Section 12.4.6.6, showed smoke barrier assembly shall be inspected and tested not less than annually and a written record of the inspection shall be maintained for review.
I. The findings of A through G were confirmed in an interview with the Maintenance Director 06/26/2023 at 3:00 PM.

Based on observation, National Fire Protection Agency (NFPA) 13 review and interview, it was determined the facility failed to ensure the sprinkler heads were maintained to disperse water effectively in the event of a fire in that the sprinkler heads were mounted more than three inches from the ceiling. The failed practice placed the patients at risk of harm from fire and had the likelihood to affect all patients admitted to the facility. The findings follow:

A. Review of NFPA 13 showed upright sprinklers with a nominal K-factor of K-14 shall be positioned so that the deflector was three inches below the celing.
B. Observation throughout the facility on 6/26/2023 at 1:17 PM showed the sprinkler heads extended more than three inches below the ceilings.
C. The findings of B were confirmed in an interview with the Maintenance Supervisor on 6/26/2023 at 3:00 PM.

Based on policy review and interview it was determined that the facility failed to have a policy in place regarding the monitoring of telemetry units. The failed pracice placed the patients at risk of going into a fatal heeart rhythm while not being montitored and had the likelihood to affect all patients on telemetry in the facility. Findings follow:

A. Observation on 06/28/23 at 1:32 showed there were two patients on telemetry monitors. There were no staff members observing the telemetry montiors.
B. On 06/28/23 a request was made for a policy regarding monitoring of patients while on a telemetry monitor. In an interview twith the Director of Nursing (DON) on 06/528/23 at 1:45 PM, she confirmed that the facility did not have a policy reagrding monitoring of patients on a telemetry monitor.
C. In an interview with Registered Nurse #1 on 06/28/23 at 1:36 PM, she stated they don't have someone sit and monitor the telemetry monitor the telemetry monitor at all times and they listen for alarms.

Based on observation and interview, it was determined the physical environment was not maintained as a safe and functional environment throughout the facility in that:

A. Floor tiles had heavy dirt and grime buildup.
B. Floors throughout had broken tiles.
C. Door facings had peeling paint and rust.
D. Staff and patient Sinks showed:
1) Faucets and sinks had rust and green residue.
2) The integrity of the countertop was not maintained in that the surface was rough to the touch.
3) The cabinet door hinges had heavy rust buildup.
E. Cabinets and countertops had broken Formica showing wood surface that is porous and cannot be properly disinfected.
F. Walls, cabinets and countertops had sticky residue.
G. Paper towel holders had rust buildup on each side.

The failed practices did not ensure the safety, functionality, cleanliness, and integrity of all surfaces. The failed practice had the likelihood to affect all patients on census and all staff. Findings follow:

A. During observation with the Registered Nurse (RN) Nurse Supervisor on 06//26/23, showed the following:
1) Emergency Department (ED):
a) Four exam rooms faucets and sinks had rust and green residue.
b) Throughout the ED, Cabinets and countertops had broken Formica showing wood surface that is porous and cannot be properly disinfected.
c) Throughout the ED, walls, cabinets, and countertops had sticky residue.
d) Throughout the ED, paper towel holders had rust buildup on each side.
e) Throughout the ED, floor tiles had heavy dirt and grime buildup.
f) Throughout the ED, floors had broken tiles.
g) Throughout the ED, door facings had peeling paint and rust.

2) Inpatient (IP) Area:
a) Nurses station, walls, cabinets, and countertops had sticky residue. Cabinets and countertops had broken formica showing wood surface that is porous and cannot be properly disinfected.
b) Throughout patient rooms, the commodes, faucets and sinks had rust and green residue.
c) Throughout IP Area, floor tiles had heavy dirt and grime buildup.
d) Throughout IP Area, floors had broken tiles.
e) Throughout IP Area, door facings had peeling paint and rust.

3) The Laboratory Area:
a) The cabinet doors and drawer handle throughout had rust.
b) Cabinets and countertops had broken Formica showing wood surface that is porous and cannot be properly disinfected.
c) Floor tiles had heavy dirt and grime buildup.
d) Floor tiles were broken and edges were lifting from water gravitating from staff bathroom.
e) Door facings had peeling paint and rust.

4) Radiology Area:
a) There was a supply dolly in the hallway with heavy rust, dirt, and grime.
b) There was a supply dolly in the hallway showing wood surface that is porous and cannot be properly disinfected.
a) Two radiology rooms faucets and sinks had rust and green residue.
b) Throughout the RAD, Cabinets and countertops had broken Formica showing wood surface that is porous and cannot be properly disinfected.
c) Walls, cabinets, and countertops had sticky residue.
d) Paper towel holders had rust buildup on each side.
e) Floor tiles had heavy dirt and grime buildup.
f) Floors throughout had broken tiles.
g) Door facings had peeling paint and rust.

B. During the observation on 06/26/23 from 1:30 PM to 3:30 PM, RN Nurse Supervisor confirmed the findings in A.



Based on observation and interview, it was determined the facility failed to maintain a safe environment in that the door exiting the Emergency Room to the outside had a gap at the bottom which allowed pests to enter. The failed practice promoted the spread of infection and had the likelihood to affect all patients, staff and visitors entering the facility. The findings follow:

A. Observation on 06/27/23 at 12:49 PM showed there was a gap at the bottom the door exiting the Emergency Room to the outside.
B. During an interview on 06/27/23, Registered Nurse Nurse Supervisor confirmed the findings in A at the time of the observation.


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Based on observation and interview, it was determined the facility failed to prevent and control likely sources of infection and maintain a sanitary environment in that there were ceiling tiles that were stained, broken and sagging throughout the facility and on the Medical/Surgical Unit. The failed practiced promoted the spread of infection and had the likelihood to affect all patients admitted to the facility. Findings follow:

A. During the tour of the facility on 6/26/23 at 12:30 PM, observation showed ceiling tiles were stained with water stains and/or a black substance, broken and sagging throughout the facility and on the Medical/Surgical Unit.

B. During an interview on 6/26/23 at 2:24 PM, the Infection Control Coordinator confirmed the findings in A.

Based on clinical record review and interview, it was determined the Facility's Interdisciplinary Team (IDT) failed to complete a plan of care (POC) and weekly reassessment after the initial assessment to update the POC for five of five (#8-#12) swing bed patients. The failed practice had the likelihood to effect continuity of care. The failed practice had the likelihood to affect all patients admitted to Swing Bed status. The findings follow:

A. During an interview on 06/27/23 at 10:30 AM, Director of Nursing (DON) confirmed there was no evidence of policies for IDT to complete a POC.

B. Review of clinical record of Patient #8 on 06/27/23, admitted 06/08/23, showed the following:
1) No evidence the IDT formulated the patient's plan of care.
2) No evidence the IDT completed the weekly assessment in the patient's plan of care.
3) On 06/27/23 at 1:30 PM, DON confirmed the findings.

C. Review of clinical record of Patient #9 on 06/27/23, admitted 06/14/23, showed the following:
1) No evidence the IDT formulated the patient's plan of care.
2) No evidence the IDT completed the weekly assessment in the patient's plan of care.
3) On 06/27/23 at 1:40 PM, DON confirmed the findings.

D. Review of clinical record of Patient #10 on 06/27/23, admitted 05/01/23, showed the following:
1) No evidence the IDT formulated the patient's plan of care.
2) No evidence the IDT completed the weekly assessment in the patient's plan of care.
3) On 06/27/23 at 1:50 PM, DON confirmed the findings.

E. Review of clinical record of Patient #11 on 06/27/23, admitted 05/16/23, showed the following:
1) No evidence the IDT formulated the patient's plan of care.
2) No evidence the IDT completed the weekly assessment in the patient's plan of care.
3) On 06/27/23 at 2:00 PM, DON confirmed the findings.

F. Review of clinical record of Patient #12 on 06/27/23, admitted 04/17/23, showed the following:
1) No evidence the IDT formulated the patient's plan of care.
2) No evidence the IDT completed the weekly assessment in the patient's plan of care.
3) On 06/27/23 at 2:15 PM, DON confirmed the findings.

Based on review of policies and procedures and interview, it was determined the facility failed to create and review policies and procedures on a biennial basis for disaster drills. The failed practice placed the patients, staff and visitor at risk of delay in response in the event of a disaster. The failed practice had the likelihood to affect all patients, staff and visitors. Findings follow:

A. A request was made on 06/26/23 for a policy and procedure for conducting disaster drills.
B. In an interview with the Maintenance Supervisor on 06/26/23 at 2:12 PM, he confirmed the facility did not have a policy and procedure regarding conducting disaster drills.