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Based on observation, interview and document review the facility was not maintained in a manner safe from fire and was found not in substantial compliance with the requirements for participation in Medicare at 42 CFR Subpart 485.623(d)(1), Life Safety from Fire, and the 2000 Edition of the National Fire Protection Association (NFPA) Life Safety Code 101, Chapter 19 Existing Health Care. The facility failed to maintain a two hour fire barrier between the building and the tunnel that leads to a pipe tunnel that leads to the medical office building, the facility failed to maintain the ratings of its smoke barriers, failed to ensure doors in smoke barriers either had self-closers or self closed completely, failed to maintain the rating of barriers surrounding hazardous areas, and failed to ensure each hazardous area was surrounded with either one hour fire rated construction or had an approved automatic fire extinguishing system and smoke resisting partitions and doors, failed to ensure its sprinkler system was maintained in a reliable operating condition, failed to have its Essential Electrical System divided into an emergency system and an equipment system. The facility failed to ensure hazardous areas were provided with protective construction in accordance with section 8.4, life safety code 101. The facility failed to have each path of egress marked within the medical office building, failed to maintain the rated barriers of its hazardous areas, and failed to have sprinklers in a hazardous area. The facility failed to ensure it had an automatic sprinkler system installed in accordance with National Fire Protection Association 13 to provide complete coverage of all portions of the facility, failed to maintain its sprinkler system in accordance with National Fire Protection Association 25, 2-3.2, and have gauges inspected or replaced every five years and failed to maintain its sprinkler heads free of dust. The facility failed to maintain a water supply which provided continuous and adequate pressure and failed to ensure its emergency area suite was less than 10000 square feet.(C 231)

Based on observation and interview, the facility failed to maintain an environment safe from fire. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of one patient at the time of the survey.

Findings include:


Building 1 of 4

The facility failed to maintain a two hour fire barrier between the building and the tunnel that leads to a pipe tunnel that leads to the medical office building. Please refer to K11.

The facility failed to maintain the ratings of its smoke barriers. Please refer to K25.

The facility failed to ensure doors in smoke barriers either had self-closers or self closed completely. Please refer to K27.

The facility failed to maintain the rating of barriers surrounding hazardous areas, and failed to ensure each hazardous area was surrounded with either one hour fire rated construction or had an approved automatic fire extinguishing system and smoke resisting partitions and doors. Please refer to K29.

The facility failed to ensure its sprinkler system was maintained in a reliable operating condition. Please refer to K62.

The facility failed to have its Essential Electrical System divided into an emergency system and an equipment system. Please refer to K145.

Building 3 of 4

The facility failed to ensure hazardous areas were provided with protective construction in accordance with section 8.4, life safety code 101. Please refer to K29.

Building 4 of 4

The facility failed to ensure each hazardous area was protected in accordance with 8.4, life safety code 101. Please refer to K29.

The facility failed to have each path of egress marked within the medical office building. Please refer to K47.

Building 2 of 4

The facility failed to maintain the rated barriers of its hazardous areas, and failed to have sprinklers in a hazardous area. Please refer to K29.

The facility failed to ensure it had an automatic sprinkler system installed in accordance with National Fire Protection Association 13 to provide complete coverage of all portions of the facility Please refer to K56.

The facility failed to maintain its sprinkler system in accordance with National Fire Protection Association 25, 2-3.2, and have gauges inspected or replaced every five years, and failed to maintain its sprinkler heads free of dust. Please refer to K62.

The facility failed to maintain a water supply which provided continuous and adequate pressure. Please refer to K63.

The facility failed to ensure its emergency area suite was less than 10000 square feet. Please refer to K130.

Based on observation and staff interview it was determined the facility failed to follow infection control procedures in dietary and environmental services. This has the potential to affect all patients receiving care in the facility. At the time of the survey the census was one patient.

Findings include:

1. Observation in the dietary department on 07/21/15 beginning at 9:40 AM revealed Staff C to prepare dishes for wash by pre-soaking (silverware) and rinsing plates, glasses, cups, bowls, saucers, trays, coffee pots and insulated lids and warming plates.

Inspection of the machine noted manufacturer labeling directed the wash cycle be a minimum of 150 degrees Fahrenheit (F) and the rinse cycle a minimum of 180 degrees F. Staff C was noted to place the first load containing trays, coffee pots with lids and glasses into the dishwasher and start the wash cycle. Staff C was then observed to turn back to load another tray for the wash. The wash cycle temperature was observed to reach only 145 degrees F. Upon completion of the cycle Staff C was observed to begin to push the tray through to wash the next tray. When questioned what the wash cycle temperature was, Staff C verified he/she had not watched and did not know. Staff C stated he/she would wash it again. The water temperature was confirmed by Staff C to reach only 146 degrees F, but was observed to push the tray through and begin the wash of the second tray which contained insulated lids, cups and glasses. The wash cycle temperature did not exceed 148 degrees F. The third and fourth trays containing trays only, reached a maximum wash temperature of 147 degrees F.
Staff C was observed to pull the trays through from the dishwasher and onto the drying counter with gloves that had been utilized handling the soiled dishes. The fifth tray containing plates and the heated plate warmer units also reached a maximum temperature of 147 degrees F.
Staff D, who was covering for the supervisor, was informed of the issues and stated maintenance would immediately be notified. Staff C continued to wash dishes with a sixth tray of insulated plate lids, cups, small dessert dishes and saucers. The wash temperature did not exceed 146 degrees F. At this time Staff E appeared and spoke with Staff C and then left to trouble shoot. The seventh tray containing insulated plate lids reached a maximum wash temperature of 147. Tray eight containing silverware was started and reached a wash temperature maximum of 148 degrees F when the machine began alarming the soap dispenser was empty. The cartridge was changed and the cycle restarted and the wash water temperature was noted to be at a minimum of 150 degrees F. Staff E stated the pilot light on the water heater had gone out.
At 10:12 AM on 07/21/15 after washing all of the dishes, Staff C recorded the ending (eighth) wash cycle temperature on the temperature log. The final rinse remained a minimum of 180 degrees F throughout. At this time Staff C verified he/she had not: Watched the water temperature through the first machine load; Rewashed the dishes that did not attain the required minimum wash temperature (at least 3 trays of which had already been put away); or Changed gloves and/or performed hand hygiene before handling the clean trays and contents.
During interview with Staff B at 2:45 PM on 07/22/15 it was verified the facility has no policy addressing dishwasher temperatures but agreed the dishes washed in sub-temperature water should have been rewashed and gloves should have been changed between handling of dirty and clean dishes.

2. Staff F from environmental services was observed performing the routine cleaning of room 103 between 10:45 AM and 11:10 AM on 07/22/15. Observation of cleaning in the bathroom noted Staff F to start by sanitizing hands and applying gloves, then cleaning the upper edges and sides of the sink, the sink bowl, the hand soap dispenser, the towel dispenser and then the mirror. Staff F then removed the commode that was placed over the toilet to substitute for a raised toilet seat and washed the toilet seat, rim, toilet bowl and commode liner (an open bottomed ring that fills the space between the commode and the toilet to prevent splashing). Staff F then performed hand hygiene, applied clean gloves and obtained a clean rag and was observed to clean the right arm rest of the commode frame, the back and legs of the frame, the lid outer and then inside surfaces, and then the outer and inside surfaces of the toilet seat that the patient sits on. Staff F was observed to wipe the left armrest as he/she was walking away to change rags and gloves with the same rag that was just used to wipe the toilet seat.
After completing all the required cleaning functions, Staff F was noted to remove the glove of the right hand, grab the trash bag with the gloved left hand and proceed to the dirty utility room for disposal of the trash. No hand hygiene was performed to the right hand after the glove removal. Staff F verified at 11:10 AM on 07/22/15, hand hygiene was not performed after disposing of the trash.
Review of the undated facility policy, "Hand Washing," noted at item "f " that hand hygiene was to be performed: "After removing sterile or non-sterile gloves."
During interview at 2:30 PM on 07/22/15 Staff A verified that cleaning should begin at the area least likely to be contaminated and proceed, with the area most likely to be contaminated being cleaned last.

Based on medical record review and staff interview it was determined the facility failed to develop a plan of care for one (#1) of one in-patients. This could potentially affect all patients receiving care in the facility. The census at the time of the survey was one patient.

Findings include:

Review of the medical record revealed Patient #1 who was admitted to the facility on 07/15/15 with a diagnosis of chronic obstructive pulmonary disease COPD exacerbation. Further review of the medical record revealed there was no care plan listing interventions or goals to direct the care and treatment of Patient #1 ' s respiratory disease, which was the reason for the hospital admission. This finding was verified during interview with Staff B at 2:42 PM on 07/20/15.

Review of policy entitled Admissions reviewed 11/2013 revealed at number 8. Interdisciplinary Care Plan Goasl are to be completed by the RN using method number 7. Perform nursing assessment and document in appropriate places.