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Based on observation and interview, the facility failed to maintain the condition of the physical plant in a manner that assured the safety of patients in that one of one fire barrier wall was not sealed with fire-proof sealant outside the Environmental Services Room. The risk of fire or smoke spreading had the likelihood to affect all patients, visitors and staff in the facility. Findings follow:

A. Review of NFPA (National Fire Protection Agency) 1: 12.9.6.2 requirements showed penetrations in a fire-rated barrier shall be protected by material restricting the transfer of smoke.
B. Observation on 09/10/19 at 02:31 PM of the wall above the fire-rated doors outside the Environmental Services Room showed three holes of 8-inch diameters present which were not fire-proof sealed per NFPA 1: 12.9.6.2 to prevent the migration of fire and smoke. One hole surrounded an HVAC pipe, and the other two holes contained cables running through the wall. This finding was verified by the Director of Maintenance at the time of observation.

Based on observation and interview, it was determined in one of one (Central Supply) storage area observed supplies were not stored 18 inches below the sprinkler deflector as required by NFPA 13:8.8.6, 2010 edition and were in the path of the sprinkler spray pattern. The failed practice had the likelihood to affect all patients and staff in that a potential fire in the Central Supply storage room would not be immediately extinguished and could spread to other nearby areas due to the spray pattern of the activated sprinklers being obstructed. Findings follow:

A. Review of NFPA 13:8.8.6, 2010 edition showed the top of storage must be at least 18 inches below the deflector of the sprinkler.
B. Observation on 09/11/19 at 09:20 AM of the Central Supply storage showed three 6-inch-tall cardboard boxes adjacently stacked on a shelf 8 inches below a sprinkler deflector. This finding was verified by the Director of Maintenance at the time of observation.

Based on observation and interview, the facility failed to ensure all patient-care equipment was maintained in safe operating condition in that no preventative maintenance was being performed for the medical gas equipment and no inventory log was being kept of medical gas supplies and equipment for 12 of 12 months requested (September 2018 - September 2019). Findings follow:

Review of the facility's preventative maintenance logs on 09/10/19 at 3:43 PM showed no preventative maintenance was being performed for the medical gas equipment and no inventory log of the medical gas supplies and equipment existed. This finding was verified by the Director of Maintenance at the time of the review.

Based on observation and interview, the facility failed to provide battery-powered emergency lighting for one of one emergency generator as required by NFPA (National Fire Protection Agency) 101, 2012 edition. The failed practice had the likelihood to affect all patients and staff in that in the event of a power outage emergency there would be no lighting to illuminate the work area around the generators, which would delay or prevent the maintenance required to keep the generators functioning. The findings were as follows:

A. Review of NFPA 101:9.1.3 2012 edition showed emergency generators must be installed and maintained in accordance with NFPA 110. Further review of NFPA 110:7.3.1 2010 edition showed emergency power equipment shall be provided with battery-powered emergency lighting.
B. Observation on 09/10/19 at 1:45 PM of the generator area showed the overhead lighting present was powered solely by the main electrical system, and no battery-powered lighting was present. This finding was verified by the Director of Maintenance at the time of observation.


Based on observation and interview, it was determined the facility failed to ensure life safety requirements for one of one medical gas storage area (near administrative suite) were met in that medical gas tanks were being stored in an interior location without required ventilation, and one of one 5-foot-tall oxygen cylinder was standing unsecured between the racks of smaller medical gas tanks. The failed practices had the likelihood to affect all patients and staff and visitors in that a high potential for explosion was created by the storage environment. Findings follow:

Observation on 09/10/19 at 01:26 PM of the oxygen storage closet showed no ventilation was present in the closet, and one of one 5-foot-tall oxygen cylinder was standing unsecured between the racks of smaller medical gas tanks. This finding was verified by the Director of Respiratory Care and the Director of Maintenance at the time of observation.

Based on observation, review of policy and interview, it was determined the facility failed to follow acceptable standards of practice in that they failed to ensure emergency carts were checked each month by pharmacy in two (Surgical Services a Breslow and adult) of four (Surgical Services a Breslow and adult, Medical/ Surgical and Emergency Department) emergency carts surveyed in the facility. The potential exists for the crash carts not to have medications/supplies present for patient emergencies. The failed practice had the likelihood to affect all patients who needed medications in an emergency. Findings follow:

A. Record review of the facility's policy titled, "Emergency Medications: Emergency Crash Carts," dated 08/05/19, showed pharmacy personnel were to do monthly inspections on each cart to monitor for proper drug storage, stock level and expiration dates.
B. During a tour of the facility on 09/09/19 from 1:00 PM to 1:45 PM, observation showed one Breslow and one adult crash cart stored in Surgical Services that had no evidence they were being monitored by the pharmacy department.
C. During an interview on 09/09/19 at 1:24 PM, the Director of Pharmacy verified the carts were not being monitored by the pharmacy department. The Director of Pharmacy explained the carts were brought in by [name] as back up carts in case they needed them, and he was not aware they contained medications.

Based on review of policy, observation and interview, it was determined the facility failed to identify that clean linens were not stored in a clean linen closet or on a clean linen cart in two of two (Treatment Room #2 and hall closet) linen storage areas in the Rehabilitation Department. By not storing linens to prevent soiling, the facility could not assure the linens were clean and not soiled when used for patients. The failed practice had the likelihood to affect all the patients that were treated in the Rehabilitation Department. Finding follow:

A. Record review of facility policy titled, "Storage of Clean Linen," dated 07/01/2008, showed clean linen was to be stored in the Clean Linen room or a Clean Linen cart.
B. During a tour of the Rehabilitation Department on 09/11/19 from 8:50 AM to 9:35 AM, observation showed the following:
1) Treatment Room #2 stored uncovered linens (sheets and towels) on two shelves in a large closet among cleaning supplies, a whirlpool and varies other supplies; and
2) Hall closet stored uncovered linens (sheets, towels, blankets and pillowcases) on four shelves. The closet also contained many equipment parts, wheelchair parts, supplies and had two vents, one in the ceiling and one that was approximately 4-6 inches off the ground against the wall.
C) During an interview on 09/11/19 at 9:18 AM, the Director of Therapy verified the findings at B.


38994

Based on policy and procedure review, observation and interview, it was determined the facility failed to maintain a sanitary environment in the kitchen in that one of one (#1) delivery man and one of one (#1) water vendor man entered the kitchen food preparation area without wearing hair nets. Failure to ensure all persons entering the kitchen food preparation area were wearing hair nets did not ensure the food being prepared was not contaminated. Findings follow:

A. Review of policy and procedure received 09/10/19 titled, "Dress Code Policy," showed a bonnet or hairnet would be worn in the kitchen at all times.
B. During tour of the Kitchen area on 09/10/19 at 9:00 AM, Delivery Man #1 and Water Vendor Man #1 were seen entering the kitchen preparation area without wearing hair nets.
C. The above findings in A and B were verified by interview with the Safety, Security and Communications Director on 09/10/19 at 9:05 AM.


40282

Based on observation and interview, it was determined the Infection Control Nurse failed to identify and control infections in that four of four adult laryngoscope blades were found unwrapped in the crash cart in one of one Medial/Surgical floor. The failed practice did not assure the equipment had been cleaned or sterilized and stored to ensure protection from damage or contamination. The failed practice had the potential to affect all patients who needed the use of a laryngoscope for intubation. Findings follow:

A. During tour of the Medical Surgical floor on 09/09/19 at 1:10 PM, 4 unwrapped laryngoscope blades were found in the top drawer of the crash cart unwrapped.
B. The findings in A were verified by the Acute Care Manager at 1:10 PM on 07/29/19.

Based on interview and review of the Infection Prevention Manuals, it was determined there was no evidence of an ongoing hospital-wide infection control program in that:
1. There was no evidence of the facility tracking, identifying, reporting, and investigating infections and communicable diseases of personal and patients for quarterly reporting in 2 (May 2019 and August 2019)of 3 (January 2019 to September of 2019) quarters.
2. There was no evidence of the Infection Prevention Committee met quarterly in 2 (May 2019 and August 2019)of 3 (January 2019 to September of 2019). Failure to have an ongoing hospital-wide infection control program did not ensure the facility was identifying, preventing, and controlling infections and communicable diseases. The failed practice had the potential to affect any staff member working in the facility or patient whose care was rendered and received in the facility. Findings follow:

A. Review of the Infection Prevention Manual on 09/10/19 showed no documentation regarding tracking, identifying, reporting or investigating infections and communicable disease of patients and personal in May 2019 and August 2019 with the last meeting noted in 02/2019.
B. Review of the Infection Prevention Committee's Manual on 09/10/19 showed no documentation of a meeting in May 2019 and August 2019 with the last meeting noted in 02/2019.
C. During an interview with the Infection Prevention Nurse on 09/11/10 at 12:15 PM, she verified findings in A and

Based on interview, it was determined there was no evidence the current owners of the facility had access to the previous owner's clinical records for 8 (October 2018 through May 2019) of 12 (October 2018 through September 2019) months requested. The failed practice did not assure clinical records were available upon request. The failed practice had the likelihood to affect all patients seen at the facility from October 2018 to June 2019. Findings follow:

During an interview on 09/09/19 at 10:55 AM, the Administrator and the Chief Nursing Officer verified there were no clinical records available prior to 06/01/19.

Based on review of policy, review of manufacturer's instructions, observation and interview, it was determined Rehabilitation Services failed to maintain one of one (whirlpool) piece of equipment necessary to be able to perform whirlpool therapy, which was listed as a treatment procedure offered in Physical Therapy's List of Procedures. By not maintaining the piece of equipment, the facility could not assure the equipment was maintained properly, remained clean and was safe for use. The failed practice had the likelihood to affect all patients who receive rehabilitation services. Findings follow:

A. Record review of the facility's policy titled, "Physical Therapy Department List of Procedures Policy," dated 06/24/2015, showed that Whirlpool was listed as a procedure the Department was offering.
B. Review of manufacturer's instructions showed the whirlpool was to be cleaned every week or more often if necessary.
C. During a tour of Rehabilitation Services on 09/11/19 from 8:50 AM to 9:35 AM, observation showed a whirlpool, connected to water, unplugged, and stored in a closet along with cleaning supplies and linens. The whirlpool was dirty, had dried up residue and discoloration in the bottom of the tank.
D. During an interview on 09/11/19 at 9:25 AM, the Director of Rehabilitation Services verified the whirlpool was not being maintained according to manufacturer's instructions. There was no evidence when the last time the whirlpool was cleaned.