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Based on observation and interview, it was determined that the facility failed to provide a safe and sanitary environment for its patients and staff.

Findings were:

"OSHA/Bloodborne Pathogen Regulations Policy #138-030-060 " stated in part " The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner. "

Facility policy entitled "Infection Control Program" stated in part "All horizontal surfaces in patient areas, except ceilings, should be damp cleaned at least daily."


Tour of the kitchen on 2/18/15 revealed the following:

· Metal warming pans were stacked while wet. When these pans were separated, water dripped onto the floor. When dishes and pans are not air dried, there is potential for bacterial growth. According to FDA Food Code 2009: Annex 3 - Public Health Reasons / Administrative Guidelines - Chapter 4, Equipment, Utensils, and Linens, "4-901.11 Equipment and Utensils, Air-Drying Required: Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms to equipment or utensils."
· A "Calibration Record for the Thermometer" dated March, 2013 was posted in the kitchen. Also posted in the kitchen was a form entitled "Ice Machine Cleaning and Sanitizing Form" dated 2012.
· The brooms and mop used to clean the kitchen appeared abraded and dirty.
· The flooring under the dish washing machine was stained and corroded. Water was noted to be dripping onto the floor creating a slip hazard for the kitchen staff.

Tour of the nursing floors on 2/18/15 revealed the following:

· High horizontal dust was noted in 4 unoccupied "clean" rooms which indicated inadequate cleaning of the area.
· The restroom in the "isolation" room had a paper towel dangling from the ceiling vent. This toweling could catch dust and appeared unsightly.
· The nourishment room, which was located in behind the nurses' station and was available to both staff and patients, had dead bugs in the fluorescent ceiling fixture. The cabinets were filled with personal dishes, condiments, opened packages of bread and other groceries. The Director of Nurses admitted that the storage of unlabeled personal foods in a patient area created a risk for cross contamination.
· Two cribs and a rollaway bed were noted to be stored in a hallway. These 3 beds appeared quite old with mattress tags that were labeled "1987." The rollaway bed's mattress was cracked which made cleaning impossible and cross contamination likely. Paint was chipped on the railing of the cribs, again making cleaning impossible.
· The mattress covers in the bassinets were stained with what appeared to be blood. These stains could be seen when the cover was opened and folded back. This indicated improper maintenance of the area.

Tour of the surgery department on 2/18/15 revealed the following:

· In Operating Room A, the flooring had brown discolorations and black spots of an unknown substance, visible throughout the room, indicating ineffective cleaning of the floor.
· High horizontal dust was noted on top of a cabinet in Operating Room B, indicating inadequate cleaning of the area.
· In the sterilization room an open area in the drywall, approximately 5 X 5 inches in size (where a phone had previously been installed), was observed beside the autoclave.

In interviews on 02/18/15, the Infection Control Nurse, Surgical Services Director, and the Director of Nurses, confirmed the above infection control issues.

Based on a review of documentation, facility policies and procedures had not all been reviewed on an annual basis, creating an opportunity for breakdowns in patient care and the overall operation of the facility.

Findings were:

During a review of facility policy and procedure manuals on 2-18-15, 4 of 14 facility policy and procedure manuals had not been reviewed within the last 12 month period or at any time during the calendar year 2014.

The policy and procedure manuals lacking annual review were:

· Dietary - last reviewed 8-1-10
· Physical Therapy/Occupational Therapy - last reviewed 8-12-10
· Emergency Room - last reviewed 8-23-12
· Health Information Management - last reviewed 10-15-13

The above information was confirmed in an interview with the Chief Executive Officer, Chief Nursing Officer and Director of Infection Prevention on the afternoon of 2-18-15 in the facility conference room.