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Based on observations, interviews, and record reviews, the facility did not meet the Conditions of Participation for Physical Environment as evidenced by the facility failed to provide a safe environment as evidence by:

1. The facility failed to ensure the call system (a device used by a patient to signal his or her need for assistance from healthcare staff) was maintained in operating condition to provide visible and audible alarm for 10 patient rooms (Rooms 322, 325, 326, 327, 328, 329, 330, 331, 333, 334) in a Medical-Surgical Unit (where non-critical patients with a wide variety of conditions are provided care).(Refer to A-724).

This deficiency resulted in the hospital's inability to ensure the Conditions of Participation for Physical Environment was met. The cumulative effects of these system problems resulted in the patients in the 10 patients rooms using their personal cell phone and/or the hospital bedside phone to request for assistance. The deficiency also had the potential to place patients at risk of not being able to request assistance for necessary care such activities of daily living (ADL, tasks of everyday life that includes eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet) and for assistance that requires immediate assistance such requesting assistance to use the toilet and/or the risk of falls with injury.

Based on observation, interviews, and record reviews, the facility failed to ensure the call system (a device used by a patient to signal his or her need for assistance from healthcare staff) was maintained in operating condition to provide visible and audible alarm for 10 patient rooms (Rooms 322, 325, 326, 327, 328, 329, 330, 331, 333, 334) in a Medical-Surgical Unit (where non-critical patients with a wide variety of conditions are provided care).

This deficiency resulted to the patients in the 10 patients rooms using their personal cell phone and/or the hospital bedside phone to request for assistance. The deficiency also had the potential to place patients at risk of not being able to request assistance for necessary care such activities of daily living (ADL, tasks of everyday life that includes eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet) and for assistance that requires immediate assistance such as requesting assistance to use the toilet and/or accidents.

Findings:

During a concurrent observation and interview on 3/18/22, at 10:10 AM with the Charge Nurse (CN) in the Medical-Surgical Unit, call lights above the door of 10 patient rooms were observed lit up but no audible sound was heard. The CN stated, "The lights outside the patient rooms are on, but the patients are not calling." The CN said, "Those steady lights turn on when the entire call light system is disabled." The CN stated that there were four (4) behavioral health patients (patients with mental health and substance abuse disorders) in the Medical-Surgical Unit, and for patient safety the staff removes the call light cord from the behavioral health patients' rooms since it is a ligature risk (anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation). The CN further stated that when a call light cord is unplugged from the wall in any patient room, an alarm goes off non-stop. The staff, therefore, disables the call light system by pressing a button that corresponds to the patient's room in the main call light panel located at the Nurses Station. The CN said, "Even if it's only one button that is disabled in the call light panel, this deactivates the entire call light system, and so other patients can no longer use their call light button to call us." The CN also stated, "When a patient presses the call light button in their room, you will not hear an alarm. You will only see a tiny red light that turns on in the main call light panel at the Nurses Station."

During a concurrent observation and interview on 3/18/22, at 10:17 AM with the CN in room 326, the use of the call light button was observed. The CN stated, "I will demonstrate to you what I was explaining earlier." The CN was observed pressing the call light button, but no audible alarm was heard. The CN also showed the extension number written on a white board inside room 326, which according to CN is the number that the patient can dial to ask for assistance.

During an interview on 3/18/22, at 10:20 AM with patient (Patient 1), in room 326, Patient 1 said that when she needs anything from the staff, she uses the hospital phone to call the number listed on the whiteboard because that was the instruction from the staff.

During a concurrent observation and interview on 3/18/22, at 10:26 AM with Registered Nurse 1 (RN 1) in the Nurses Station, the main call light panel was observed to have a small red tiny light lit up for room 326. RN 1 stated, "That small red light in the panel means the patient from room 326 pressed her call light, and that is the only indication you will know that she called since there is no alarm that went off." RN 1 also said that you will only see the small red button lit up if you are sitting or standing directly in front of the main call light panel because "the red light is so small." RN 1 further stated, "That's why we just ask our alert and oriented patients to give us a call when they need help, and we also do frequent rounds (intentionally checking on patients at regular intervals) on our other patients who are unable to call."

During an interview on 3/18/22, at 10:35 AM with Registered Nurse 2 (RN 2), RN 2 stated, "We do frequent rounds almost every 15 minutes on our patients who cannot call." When asked to show a documentation of the frequent rounding done, RN 2 said that staff don't document their every 15 minutes rounding in the observation sheet. RN 2 also stated, "We have reported (dates not provided) the problem we have with the call light system every time we get behavioral health patients, but Engineering department said they cannot fix it. It has been an ongoing problem that nurses were reporting, so the only remedy we had was to ask our patients to use their phones to call us from their rooms or we do frequent rounding."

During an observation on 3/18/22, at 10:41 AM with the CN, the call lights were tested and observed for rooms 322, 325, 327, 328, 329, 330, 331, 333, and 334. The red lights for each room lit up at the main call panel at the Nurses Station, but there was no sound or alarm heard.

During an interview on 3/18/22, at 1:50 PM with a patient (Patient 2), in room 334, Patient 2 stated, "The staff told me to call when I need something. I use my own cellphone."

During an interview on 3/18/22, at 2:02 PM the Director of Facilities Management (DFM) stated that when the staff unplugs a call light cord from the wall in any of the patient rooms in the Medical-Surgical Unit, the alarm goes off and the only way for staff to silence the alarm is to press the button that corresponds to the patient's room at the main call light panel in the Nurses Station. The DFM stated, "If staff presses that small button at the main panel, it kills the entire audio." The DFM further stated, "The entire call system is disabled so you won't hear the call light sound if the patient calls from their rooms. You will only see the small red light turned on in the main call light panel." The DFM also stated, "The only remedy is to replace the entire call light system and get a different call system, but I don't know if that will happen."

A review of the facility's policy and procedure (P&P), titled, "Call light/Patient communication," dated 3/2021, the P&P indicated, "Purpose: to ensure means for patient to communicate their needs and obtain assistance if necessary ...all patients will be provided with a call system appropriate to their level of function. In the absence of appropriate or functional call system, staff will conduct and document observation of patient every 15 min (minutes)."

A review of the facility's policy and procedure (P&P), titled, "Nurse Call System failure," dated 10/2020, the P&P indicated, "In the event of malfunction and/or failure of the nurse call system, the procedure noted below will be followed: notify the facilities director or designee immediately, Engineering Department personnel will attempt to identify the cause of the malfunction and repair the system ..."

A review of the facility's Medical Equipment Management Plan for year 2022, the Plan indicated, "The Medical Equipment Management Plan encompasses routine inspections, maintenance, and testing equipment of patient care ..."

Based on observations, interviews, and record reviews, the facility did not meet the Conditions of Participation for Infection Prevention and Control and Antibiotic Stewardship Programs by failing to:

1. Have an effective pest control program that ensures maintaining a clean kitchen environment without the presence of pests (cockroaches) in the facility's kitchen that provided meals (breakfast, lunch, and dinner) to the one hundred thirty-six (136) patients out of one hundred thirty six patients. (Refer to A-750).

These deficiencies resulted in the hospital's inability to ensure the Conditions of Participation for Infection Prevention and Control and Antibiotic Stewardship Programs was met. The facility's kitchen was temporarily closed due to pest (cockroaches) infestation from 3/17/22 to 3/22/22. The presence of pests (cockroaches) in the kitchen had the potential to spread communicable diseases (as infectious diseases, illnesses that result from the infection, presence and growth of pathogenic biologic agents [a microorganism that causes or can cause diseases] from an individual human or other animal host) carried and or transmitted by waste products and contaminated surface.

Based on observations, interviews, and record reviews, the facility failed to ensure that the one hundred thirty-six patients out of one hundred thirty-six patients in the facility receiving meals (breakfast, lunch, and dinner) from the facility's kitchen was free from sources and transmission of infection from pests (cockroaches) by failing to:

1. Maintain and implement an effective (pest control) program of monitoring, prevention, and control the presence of pests, and implement monthly or more often if necessary to maintain control of all pests according to the facility's pest control program policy and procedure (P&P) to ensure cockroaches were not found present in the kitchen.

2. Maintain a clean and sanitary environment in facility's kitchen areas that was free of debris (food wastes) on the floor, gaping hole at the drainboard, and cracks in the tiles and walls in the kitchen.

These deficient practices resulted to the closure of the facility's kitchen, on 3/17/22 by the local health department due to the presence of cockroaches in the kitchen. The presence of cockroaches had the potential to spread communicable diseases (as infectious diseases, illnesses that result from the infection, presence and growth of pathogenic biologic agents [a microorganism that causes or can cause diseases] from an individual human or other animal host) carried and or transmitted by waste products and contaminated surfaces.

On 3/17/22, at 6:28 p.m., an Immediate jeopardy (IJ-a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, or impairment, or death to a patient) was identified of the facility's deficient practice for not having an effective (pest control) program of monitoring, prevention, and control the presence of pests in the kitchen, in the presence of the facility's Chief Operating Officer (COO), Administrative Director of Operations (ADO), and the Director of Food and Nutrition (DFN).

On 3/21/22 at 2:59 p.m., the IJ was removed after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practices). The elements of the IJ Removal Plan were verified and confirmed through observation, interview, and record review. The IJ was removed in the presence of the facility's COO, Chief Nursing Officer (CNO), and Chief Executive Officer (CEO).

The acceptable removal plan was as follows:

1. On 3/17/22, the facility provided meals to their patients using outside service vendors until 3/22/22 when the facility plans to reopen their facility kitchen.

2. On 3/17/22, the facility contacted a contracted pest control service which completed treatment of the entire dietary area including the kitchen and dishwash room area.

3. On 3/17/22, the facility's leadership team met and developed an action plan to address the cleaning and repair of the kitchen. The plan included the closing of the kitchen, terminal deep cleaning, and repair of all interior structural gaps to prevent pest activity.

4. On 3/18/22, the facility's contracted cleaning service completed a terminal cleaning of the kitchen, and the facility implemented a quarterly terminal deep cleaning of the kitchen and dishwash room area.

5. On 3/19/22, the facility obtained a new cleaning and pest control company due to ineffectiveness of previous service contract.

6. On 3/20/22, the second kitchen cleaning was completed by the new cleaning company. Cleaning included walls, floors, ceilings, and all surfaces. All cooking utensils were cleaned and sanitized prior to being returned to the terminally cleaned kitchen.

7. On 3/21/22, the facility's contracted pest control company completed fumigation (a method of pest control by completely filling an area with gaseous pesticides to poison the pests within) of the kitchen area followed by another kitchen cleaning by the cleaning service company.

8. On 3/21/22, the facility updated their pest control plan to include pest sighting procedures, which included the monitoring, recording, and reporting pest activity by the kitchen staff to their immediate supervisor.

9. On 3/21/22, the facility completed a mandatory staff education on the following topics: pest sighting procedures, recognition of pest activity, required actions when pest activity is observed, and reporting requirements.

Findings:

On 3/17/ 22, at 12:00 p.m., a visit was made to the kitchen located in the basement of the facility for an investigation of cockroaches.

1. During an interview on 3/17/22, at 12:15 p.m., with the Environmental Health Specialist (EHS), EHS stated that he (EHS) observed the following in the ware-washing room located in the basement:

a.) There was one (1) live adult cockroach on the floor under the 3-compartment sink.
b.) There were two (2) live adult cockroaches in the wall behind a displaced metal ring under one compartment utensil wash-down sink.
c.) There was one (1) live adult cockroach in a glue trap on the floor located in the chemical storage room.
d.) There were five (5) dead nymph cockroaches in a glue trap on the floor on the floor located in the chemical storage area.

During an interview on 3/17/22, at 12:15 p.m., with the Environmental Health Specialist (EHS), the EHS also stated that the kitchen food preparation area, kitchen ware-washing room (the cleaning and sanitizing of utensils and food-contact surfaces of equipment), and cafeteria was officially closed (no use of the kitchen food preparation area, ware-washing room, cafeteria, and dining area) at 10:00 a.m., on 3/17/22, by the EHS due to an infestation of cockroaches.

On 3/17/22, at 12:30 p.m. during a general observation tour of kitchen ware-washing room located in the basement with the EHS, the following were observed:

1) Two (2) live adult cockroaches in the wall behind a displaced metal ring under one compartment utensil wash-down sink (an area where kitchen equipment is cleansed using water or other liquid).
2) There were three (3) dead nymph cockroaches in a glue trap on the floor in the chemical storage room.
3) There were two (2) dead adult cockroaches on the floor at the chemical storage room.

On 3/ 18/22, at 9:00 a.m., during a tour of the kitchen ware-washing area, kitchen food preparation room, and cafeteria, the evaluators, in the presence of the facility's team members (who worked with the facility's pest control program) that included the Director of Facilities Management (DFM) and the Administrative Director of Operations (ADO) observed the following and was confirmed by the DFM and the ADO:

1) There were five (5) outdated glue traps for cockroaches that were dated 1/6/22 and 1/8/22, on the floor at the kitchen food preparation area. No cockroaches seen on glue traps.
2) There were three (3) outdated glue traps for cockroaches that were dated 1/2/22, located at the Kitchen ware-washing room. No cockroaches seen on glue traps.
3) There was one (1) outdated glue trap for cockroaches that was dated 1/6/22, located in the cafeteria by the microwave. No cockroaches seen on glue traps.

During an interview on 3/18/22, at 9:30 a.m., the DFM and the Administrative ADO stated that the pest control company visits weekly, usually on Tuesdays to set glue traps, remove glue traps, and spray the kitchen for cockroaches. They (DFM and ADO, both oversee the facility's infection prevention program) also stated that they do not know why the pest control company did not collect and replace the glue traps for cockroaches that were dated 1/2022 since the pest control company visits every Tuesday. They (DFM and ADO) also stated that glue traps are replaced every month if there are no cockroaches caught in the glue traps.

A review of the Pest Control Company Contract titled, "Service Agreement," dated 4/10/09, indicated that pest control, "Service weekly on Tuesday ...for kitchen, dishwashing room, cafeteria, storage area."

During an interview, on 3/18/22, at 11:30 a.m., the DFM stated the facility contract for pest control service was on-going since 4/2009, and that the facility has not canceled the pest control company contract. The DFM also said that they relied on the pest control company to perform what was in the contract, but that the facility did not also check if the pest control company was actually replacing outdated glue traps.

A review of the facility's Pest Control Reports from 10/2021 to 3/2022 (6 months' time period done weekly), conducted on 3/18/22, titled, "Quality Assurance Report," from the facility's Pest Control Company Service, indicated no treatment for cockroaches and no written information for the presence of cockroaches found in the kitchen, cafeteria, storage, offices, and dish room. The following reports for dates: 3/15/22, 3/8/22, 3/1/22, 2/1/22, and 12/7/21, indicated, "Spot treatment under sink, cabinet, prep table, oven, crack, and crevice ...also check pest monitors and replaced on kitchen, cafeteria, storage, offices and dish room."

During an interview on 3/18/22, at 2 p.m., the DFM stated that the pest control company service recommended, "Thorough cleaning (included cleaning of walls, floors, ceilings, and all surfaces)" of the entire kitchen area (ware-washing room, food preparation room, storage areas), but the facility's contracted janitorial service included under the pest control service agreement has not thoroughly cleaned the areas in many years recommended by the pest control company.

During an interview on 3/18/22, at 2:17 p.m., the DFN stated the local health department environmentalist arrived at the facility on 3/17/22, around 7 a.m., and closed the kitchen area before 12 p.m., on 3/17/22, due to the environmentalist's sighting of live cockroaches in the kitchen.

During a tour of the kitchen on 3/19/22, at 4:10 p.m., with the facility's Engineering staff (who work with the facility's infection control program team), five (5) live small roaches were observed under the drainboard (a fixed platform attached to a kitchen sink that allows water to drain while dishes are resting that helps to dry dishes).

A review of the facility's P&P, titled "Infection Control-Dietary," dated 4/2019, indicated, "Pest control: the objective is to maintain a sanitary environment, and preventing contamination/spread/transmission of disease by insects or rodents ...the evidence of pests found by employees will be reported to the kitchen supervisor and Engineering ..."

A review of the facility's policy and procedure (P&P) titled, "Pest Control," dated 12/2021, indicated, "Pest control will be done monthly or more often if necessary to maintain control of all pests encountered ...good housekeeping, proper sanitary practices and food storage are the first steps in controlling crawling insects ..."

A review of the facility's P&P, titled, "Infection Control Plan 2022," dated 3/2022, indicated, "To maintain a comprehensive and effective program of surveillance, prevention, and control of infection ..." The P&P further indicated, "Purpose: to identify and reduce the risk of development and transmission of healthcare-acquired infections among patients, healthcare workers, visitors, and others in the healthcare environment."

2. A review of the facility's, "Retail Food Official Inspection Report," dated 3/17/22 with time in at the facility at 7 a.m. and sign out 4 p.m., indicated findings and facility instructions that include:
a.) "Gaping holes in walls (example-observed approximately 2' x 3' hole in wall behind one of the drainboard back-splashes) ..."
b.) "Gaps around the clean-out drainpipes located in wall under the food preparation sink ..."
c.) "Remove accumulation of debris from between floor tiles in the kitchen (next to the cooking equipment)."
d.) The facility permit was suspended, and operation was discontinued due to findings, "Pose an immediate danger to public health and safety."

During a tour of the kitchen and concurrent interview with the facility's Engineering staff, on 3/19/22, at 4:10 p.m., debris and cracks were observed on the floor tiles near the three (3) compartment sink. The drainboard had a new sealant (a modern solution to sealing sink drains). Engineering staff stated using caulking sealer to seal the gap (gap identified on the facility's Retail Food Official Inspection Report, dated 3/.17/22), on the drain board.

During a tour of the kitchen, on 3/19/22, at 4:45 p.m., at the chemical storage area, multiple cracks were observed in the walls and tiles.

A review of the facility's P&P, titled "Infection Control-Dietary," dated 4/2019, indicated for cleaning, the facility was to, "Maintain the greatest degree of sanitation possible in all food areas to prevent growth of bacteria in all areas." The duties will be divided among dishwasher operators, cafeteria employees, cooks and food servers. The Engineering/Environmental services will be responsible of cleaning floors.

A review of the facility's P&P, titled, "Pest Control," date 12/2021, indicated, to eliminate infestation in problem areas, facility was to, clean up food wastes promptly to help reduce infestation at the start.