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Based on observation and interview, it was determined that the facility was not always maintained in a manner to ensure staff and patient safety.

Findings were:

The facility had cracked floor tiles and chipped cabinetry which made thorough cleaning impossible. Wall gouges were noted behind the back of chairs and medical equipment.

These findings were confirmed by administrative staff during the tour of the facility on 6/21/22.

Based on observation and interview, it was determined that the facility did not always practice effective infection control.
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."

Tour of the facility on 6/21/22 revealed the following:

* An accucheck blood glucose machine and all of its supplies were found in the patient restroom of the ED. The machine and supplies were unsecured and were at risk for cross contamination.
* The facility had bugs in the overhead fluorescent lighting fixtures throughout.
* The facility had cracked floor tiles and chipped cabinetry which made thorough cleaning impossible.
* The facility had cracked doors and door-frames throughout, which made thorough cleaning impossible.
* In patient room # 106, an air conditioning vent in the restroom was noted to be covered in dust. The shower had chipped flooring.
* In the patient nutrition room, a copious amount of dust was found on top of the ice machine and the ceiling had a spot with bubbling noted
* In the patient shower room, the vent was dirty and there was chipped tile around the shower frame
* The inpatient hallway exterior door had sunlight coming through the bottom, which can serve as an entry point for insects
* In the dishwasher room, there was chipping paint on the walls, door-frame and ceiling tiles and the vent was rusted, making it impossible to be cleaned

In an interview with administrative staff on 6/21/22 who were conducting the tour, the above concerns were confirmed.