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Based on observation, record review, and staff interview the hospital failed to maintain the facility as indicated by water leaks, stained ceiling tiles, lack of hot water in 2 bathrooms, and exposed electrical wiring to ensure the safety of the patients. These failures have the potential to cause harm to all employees and patients.



Findings include

1. Observation on 3/5/24 at approximately 12:00 p.m., revealed approximately six (6) ceiling tiles which appeared water stained in Office 208 of the Old Building.

2. Observation on 3/5/24 at approximately 12:06 p.m., revealed missing ceiling tile in the Business Office Bathroom of the Old Building.

3. Observation on 3/5/24 at approximately 12:13 p.m., revealed a window air conditioner loaded with dust/debris in the Kitchen Pre-Wash Area.

4. Observation on 3/5/24 at approximately 12:14 p.m., revealed an insulated plumbing line coming from the ceiling in the Kitchen Pre-Wash Area, which appeared to be stained with a black substance.

5. Observation on 3/5/24 at approximately 12:15 p.m., revealed the ceiling tile above the window air conditioner in the Kitchen Pre-Wash Area, which was peeling and appeared loaded with dust/debris.

6. Observation on 3/5/24 at approximately 12:24 p.m., revealed the men's and women's restrooms in the basement of the Old Building near the Recreation Lounge (Room B21), which were missing ceiling tile.

7. Observation on 3/5/24 at approximately 12:25 p.m., revealed the men's and women's restrooms in the basement of the Old Building were closed off and labeled as "out of order", but were found to be unsecured and appeared to have been used. Interview with the Maintenance Acute Technician noted that these restrooms have been "out of order" for approximately three (3) years due to the missing ceiling not being replaced and plumbing that needs repaired in these restrooms.

8. Observation on 3/5/24 at approximately 12:26 p.m., revealed exposed electrical wiring, which was not contained in a junction box, above the ceiling in the Men's Restroom near the Dining Room in the basement of the Old Building.

9. Observation on 3/5/24 at approximately 12:36 p.m., revealed approximately five (5) ceiling tiles in the Medical Records Storage room in the basement of the Old Building, which appeared to be water stained.

10. Observation on 3/5/24 at approximately 12:41 p.m., revealed ceiling tile outside of the Men's Restroom near Room B57 in the basement of the Old Building near Room B57, which appeared to be water stained.

11. Observation on 3/5/24 at approximately 1:04 p.m., revealed approximately seven (7) ceiling tiles in Medical Records (Room B57) in the basement of the Old Building, which appeared to be water stained.

12. Observation on 3/5/24 at approximately 1:09 p.m., revealed approximately twelve (12) ceiling tile in the corridor in the basement of the Old Building, which appeared to be water stained.

13. Observation on 3/5/24 at approximately 1:13 p.m., revealed a toilet in the Women's Restroom in the basement of the Old Building, which had a significant water leak from the back of the toilet that ran across the restroom floor when flushed.

14. Observation on 3/5/24 at approximately 1:15 p.m., revealed two (2) hand sinks in the Women's Restroom in the basement of the Old Building, which did not have hot water for hand washing.

15. Record review on 3/5/24 at approximately 3:49 p.m., revealed no documentation of any work orders that may have been entered by staff, related to the noted issues in the basement area of the Old Building, which may have been received or addressed by Maintenance/Facilities, as there was no available documentation of work orders for the previous twelve (12) months.

16. Interview on 3/5/24 at approximately 3:50 p.m., with the Director of Plant Operations and the Director of Quality/Risk Management verified these findings. These findings were also acknowledged by the Chief Executive Officer at the exit interview on 3/5/24 at approximately 5:24 p.m.

The facility failed to maintain a safe environment as a potential fall risk was identified from a leaking toilet in the basement area, no hot water was available at hand sinks in the basement women's restroom, ceiling tile was water stained throughout the basement areas, and exposed electrical wiring was identified in accessible "out of order" restrooms in the basement area. These failures have the potential for patients and staff to be exposed to environmental and electrical issues. (IJ) was called on 03/05/24 at 2:41 p.m. and removed on 03/05/24 at 5:02 p.m after onsite verification of interventions. Condition level non-compliance remains.

The following interventions were implemented to resolve the IJ: The basement bathrooms intended for patient use in the basement of the Old Building will not be utilized until the leaking toilet and hot water have been repaired. The stained ceiling tile throughout the basement areas of the Old Building have been ordered for replacement. The "out of order" men's and women's restrooms near the Dining Room water-stain dyed and locked to prevent entry.