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Based on observation, staff interviews, and review of maintenance records between August 05 through August 07, 2025, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.
Findings include

The facility was found to contain the following deficiencies.

Building 02

K131 Multiple Occupancies-Sections of Health Care Occupancies
K200 Means of Egress - Other
K341 Fire Alarm System - Installation
K920 Electrical Equipment - Power Cords and Extension Cords
C930- Life Safety from Fire

As a result of these deficiencies, 42 CFR 485.623 Condition of Participation: Physical Plant and Environment was NOT MET.

See C930, and K-tags for details of the specific findings.

Based on record review and interview the facility staff failed to ensure that patient care equipment is maintained in safe operating condition in 1 of 11 patient care areas observed (Rehabilitation Department), in a total sample of 11 patient care departments observed.

Findings Include:

On 08/05/2025 beginning at 11:10 AM, observed the Physical Therapy department containing exercise equipment used by patients during therapy.

Review of user manuals for the patient exercise equipment used in Physical Therapy revealed the following:
-Treadmills Preventative Maintenance Schedule required inspections weekly, monthly, quarterly, bi-annual, and annual. Per user manual, "Follow the schedule...to ensure proper operation of the product."
-Versa Climber Maintenance Instructions revealed, "In order to maintain highest safety level of equipment, a regular examination is required for damage and wear. This requires a visual inspection of connectors, cables, chains, sprockets, pedals, handles etc. on a regular basis.
-Upper Body Cycle Maintenance Instructions revealed that Annual Maintenance is required, including; adjusting Axial Play, Lube Chain, Lube Idler Rollers, Lube locking Knobs, Lube Chair Slide Rail, and Chair inspection.
-Tru-Kinetics Uppercycle Maintenance instruction revealed, "...periodic inspection should be performed on high use components: crank arm assemblies (hand grips, detents, locking knobs), gas spring, and height adjustment lever."

Per interview with Rehabilitation Manager J on 08/05/2025 at 11:34 AM, Manager J stated that staff do not do safety checks/inspections on the patient exercise equipment in the Physical Therapy department. Manager J stated there was no policy and procedure for equipment inspections.

Per interview with the Director of Rehabilitation EE on 08/05/2025 at 4:45 PM, Director EE stated that staff use manufacturer guidelines for machine maintenance and stated that there is no regular maintenance/inspections required for the exercise equipment. This is inconsistent with the equipment user manuals reviewed.

Based on observation, staff interviews, and review of maintenance records between August 05 through August 07, 2025, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings include

Building 02

K131 Multiple Occupancies-Sections of Health Care Occupancies
K200 Means of Egress - Other
K341 Fire Alarm System - Installation
K920 Electrical Equipment - Power Cords and Extension Cords

As a result of these deficiencies, 42 CFR 485.623(c) Life Safety from Fire was NOT MET.

See K-tags for details of the specific findings.

Based on observation, record review and interview the facility staff failed to ensure staff have access to emergency equipment for use as per policy in 1 of 1 eyewash station observed (Emergency Department), in a total of 1 eyewash station observed.

Findings Include:

Review of policy and procedure titled, "Eyewash Stations and Emergency Shower Policy" revised 07/01/2025 revealed:
-"All installed emergency showers and eyewash stations must be located within 55 feet (no more than 10 seconds travel time) from the hazard that requires the installation."
-"Emergency shower and eyewash stations must be located on the same level as the hazard and the path of travel must be free of obstructions that may inhibit the immediate use of the equipment."

On 08/06/2025 at 9:55 AM, while touring the Emergency Department (ED) with Building Services Manager DD, observed the Eyewash Station in the Ambulance Bay of the ED. Per observations, there were 2 automatic opening doors that staff would need to wait for and go through to access the eyewash station, which could delay immediate use of the equipment.

Per interview with Manager DD at the time of the observation, Manager DD stated that there was only 1 Eye Wash Station in the ED. Manager DD performed a distance check and stated that the distance from some of the ED rooms and areas to the Ambulance Bay eyewash station was more than 55 feet and could pose a concern with immediate use of the eye wash station.

Based on observation, record review and interview the facility failed to dispose of outdated supplies in 4 patient care areas (Medical-Surgical Nursing Unit, Housekeeping, Post Anesthesia Care Unit and the Laboratory department) out of a total of 11 patient care departments observed.

Findings Include:

Review of facility policy #KT2N6QC5SZE5-3-3005, last review date 04/28/2025 titled, "Storage and Handling of Patient Care Supplies and Healthcare Facility Sterilized Products Policy," revealed, "Supplies with expiration dates must be checked regularly to identify and remove items which have expired."

Examples on the Medical Surgical Unit:

On 08/05/2025 from 9:45 AM-11:30 AM during a tour and observation of the medical surgical nursing unit observed the following:
Room 109 nursing supply server 2 telemetry patch packages with an expiration date of 08/16/2024, 4 telemetry patch packages with an expiration date of 08/01/2025 and 1 telemetry patch package with an expiration date of 06/05/2025.
Room 112 observed Sanicloth wipes on the counter with an expiration date of 05/2025.

At 10:00 AM an interview on 08/05/2025 with RN (Registered Nurse) L, when asked if these supplies were expired, L stated, "Yes, Staff should be checking expiration dates, I will get rid of them."

Examples in Housekeeping:

On 08/05/2025 from 2:00 PM-3:00 PM during a tour and observation of the housekeeping areas in the facility observed the following:
In the Housekeeping supply room on the medical surgical unit observed 1 bottle of good sense cleaner with an expiration date of 09/25/2023 and a bottle of handsoap with an expiration date of 10/2024.
On the housekeeping cleaning cart in the housekeeping storage area observed 2 bottles of hydrogen peroxide with an expiration date of 11/02/2023 and 08/21/2024, a bottle of hand sanitzer with an expiration date of 03/2025.

At 2:30 PM in an interview on 08/05/2025 with Housekeeping Manager R, when asked about the expired products in the housekeeping areas, R said the expired products should have been removed.


50643


Example in Post Anesthesia Care Unit (PACU):

On 08/05/2025 at 9:43 AM during a tour and observation of the PACU observed the following:

Malignant Hyperthermia Cart: Two 55cc vials of Sterile Water with an expiration date of 08/01/2025.

During an interview on 08/05/2025 at 09:44 AM Operating Room (OR) Manager F stated she will take care of the expired supplies.

Example in Lab:

On 08/05/2025 at 11:25 AM during a tour and observation of the Lab observed the following:

Supply Drawer: Four Microtainer tubes with an expiration date of 07/31/2025.

During an interview on 08/05/2025 at 11:26 AM Lab Manager D stated she will take care of the expired supplies.

Based on record review, observation and interview the facility failed to ensure patients receive safe quality food by failing to remove unlabeled and undated food items in 1 (Kitchen) of 3 food storage areas observed.

Findings Include:

Review of facility policy #E44FHF34YSFX-6-450, last reviewed 01/27/2025, titled, "Food and Nutrition-Nursing Unit Stock Policy-Acute Care," revealed, "Complete an orange label for each type...of item and place the label on the outside of the zip lock bag...Discarding of expired items is the responsibility of Food Service staff and is done according to established guidelines."

On 08/05/2025 from 11:30 AM - 12:30 PM during a tour and observation of the facility kitchen observed the following in the kitchen freezer:
1 package of white diced meat that was not sealed, did not have an open date, and wasn't labeled
1 package of white meat no date and no label
2 packages of green food with no date and no label

On 08/05/2025 at 12:00 PM in an interview with Dietary Manager S, when asked if all frozen foods should be labeled and dated, S stated, "Yes, I'll get rid of them."

Based on record review and interview the facility staff failed to ensure all staff received job orientation/education and were competent to perform their job duties in 2 of 14 personnel files reviewed (Operating Room Manager F, Surgical Technician UU), in a total of 14 personnel files reviewed.

Findings Include:

Review of policy and procedure titled, "Annual Competency Standards Policy" last revised 04/15/2022 revealed:
-"Manager or designee is responsible for developing and maintaining a system for employee annual competency plans.
-"Employee is responsible for completing the annual competencies and will work with a validator to complete."

Review of personnel files with Regulatory Coordinator FF and Education BB, on 08/06/2025 beginning at 10:00 AM revealed there was no documented evidence of Operating Room Manager F and Surgical Technician UU receiving a job orientation/education to ensure staff are competent to perform their job duties.

Per interview with Manager F on 08/06/2025 beginning at 11:36 AM, Manager F stated that she was unable to find evidence of an orientation to the OR Manager role in her personnel files. Manager F stated that she was unable to find evidence of Surgical Technician UU's receiving an orientation to the Surgical Technician position.

Per interview with Educator BB on 08/06/2025 beginning at 11:00 AM, Educator BB stated that staff should have orientation/competencies completed on hire and annually.

Based on observation, interview and record review, facility staff failed to remove gloves and/or perform hand hygiene as per policy in 2 of 4 patient care observations of hand hygiene/glove changes (Patients #11 and #24) and 1 of 3 (Sterile Processing (SP) Tech AA) equipment cleaning observations; and failed to maintain equipment integrity to prevent infection in 1 (Loyal Clinic) out of 11 hospital departments surveyed.

Findings Include:

A review of the facility's policy titled, "Standard Precautions" last revised 08/27/2024 revealed, "...Gloves must be changed after contact with each patient...or when heavily contaminated..."

During an observation on 08/05/2025 beginning at 11:27 AM, Lab Technician E was observed drawing blood on Patient #24 with gloves. Lab Technician E failed to remove gloves and perform hand hygiene before touching a clean surface.

During an observation on 8/06/2025 at 09:45 AM, SP Tech AA was observed cleaning a colonoscope with gloves and then touched clean supplies without removing gloves or performing hand hygiene.

During an observation on 08/06/2025 at 10:36 AM, Gastrointestinal (GI) Medical Doctor (MD) Z entered, made contact with, and left Patient #11's Post Anesthesia Care Unit (PACU) bay without performing hand hygiene.

During an observation on 08/06/2025 at 10:47 AM, PACU RN B entered, made contact with, and left Patient #11's PACU bay without performing hand hygiene.

During an interview on 08/05/2025 at 11:40 AM Lab Manager D stated that she would expect lab technicians to remove their gloves and performing hand hygiene before touching clean surfaces.

During an interview on 8/06/2025 at 1:20 PM Operating Room (OR) Manager F confirmed there were missed opportunities for hand hygiene.


50644


During a facility tour starting on 8/6/2025 at 8:00 AM, observed 3 bean bag weights in the traction room (1.106) with torn edges and holes in them, not allowing for proper cleaning to prevent infection.

During an interview on 8/6/2025 at 10:05 AM, Quality W stated, "Mock tracers are completed every 6 months to check for integrity of equipment such as tears and rips and a monthly accreditation readiness checklist is completed by department staff to check for this also."