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Based on observations, interviews and record review the facility failed to ensure mechanical and patient-care equipment was maintained in safe operating condition or removed from patient care and identified as non-working equipment.

Specifically,

1.) Patient Room 108 identified as ready, contained a non-working bed that had not been removed from patient use or identified as non-working, and;

2.) Labor and Deliver Room (LDR) #2 identified as ready, contained a hand washing sink that did not have running water.

Findings included:

1.) Observation on 3/27/2023 at 10:00 AM with facility staff #6 revealed that Room 108, which was identified to surveyors as a patient ready room, had a bed with the controller affixed to the bed with tape. There was no tag or identifying information that the bed was not working.

Interview with facility staff #6, at the time of the observation (3/27/23 at 10:00 AM), confirmed the above findings and stated the bed does not work and should have been tagged and removed.

Record review of facility policy Work Request Management rev. 10/22/2022 states in part,

"REPORTING AND CONTINUOUS IMPROVEMENT. Site Leadership will be required to report information to Forefront Corporate Leadership, upon request. In the event a request is made, Forefront Corporate Leadership will be specific in their request and will assist in obtaining the information. Reporting maybe requested via email or via Vector EHS. Upon submission, continuous improvement documentation will be provided to Site Leadership. Continuous improvement is key to providing a Safe and healthy environment to the patients/residents we serve..."

2.) Observation on 3/27/2023 at 09:55 AM with facility staff #6 revealed that LDR Room #2; identified as a patient ready room had a clean handwashing sink without running water. There was no information identifying the sink as not working.

Interview on 3/27/23 at 09:55 AM with the facility staff #6 at the time of the observation confirmed the above findings and stated that she was unaware that it was not working.

Interview with facility's Director of Facility Management on 3/27/23 at 2:35 PM stated that the faucet had stopped working before and; it was a reoccurring issue.

Review of the Previous work order dated 7/26/2022 confirmed previous repair of the sink in LDR Room #2.

Record review of facility policy "Work Request Management" rev. 10/22/2022 states in part, " REPORTING AND CONTINUOUS IMPROVEMENT. Site Leadership will be required to report information to Forefront Corporate Leadership, upon request. In the event a request is made, Forefront Corporate Leadership will be specific in their request and will assist in obtaining the information. Reporting maybe requested via email or via Vector EHS"




26870

Based on observations, interviews and record reviews, the facility failed to provide surgical services in a manner to ensure the health and safety of patients.

Specifically, sterile processing procedures were not performed in a safe manner in accordance with acceptable standards of practice and in accordance with guidelines governing surgical services and recommendations promoted by or established by nationally recognized professional organizations.

These deficient practices placed the patients' health and safety at risk for the transmission of infections and/or communicable diseases.

The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Surgical Services.

Findings included:

Observations conducted on 3/28/23 at 1:33 PM of the facility's Sterile Processing Room revealed the following:

-Two clean endoscopes hanging on hooks that were attached to the wall. Both scope ends were touching the wall baseboards that contained debris and dust. The wall had sticky double sided tape attached where the scopes were hanging which did not allow a wipeable surface.

-The "Steris" Washer Disinfector had indicated the sterile cycle was completed. Within the washer were multiple baskets with surgical instruments. One basket contained surgical instruments; scissors, retractor, scalpel, and tweezers that were not separated amongst each other. They were stacked or lying on top of each other not allowing the complete disinfection of all sides of the surgical instruments. There were multiple pairs of scissors that were observed in the closed position and lying on top of each other.

Further observations conducted on 3/29/23 at 1:15 PM of the facility's Sterile Processing Room revealed the following:

-The "Steris" Washer Disinfector had indicated the sterile cycle was completed. Within the washer was one tray of surgical instruments. The metal flat tray contained surgical instruments; scissors, retractor, scalpel, and tweezers that were not separated amongst each other. They were stacked or lying on top of each other on the tray; not allowing the complete disinfection of all sides of the surgical instruments. There were multiple pairs of scissors that were observed in the closed position and lying on top of each other.

-A supply drawer contained the "Medline" surgical instrument self-seal sterilization pouches had a large yellow floor door stopper lying on top of the bags. The yellow floor stopper had black grime, debris, and large hairs present.

-Another supply drawer contained multiple packaged supplies including retractor tip protectors, surgical duo guards that were lying on top of batteries, and hand tools that appeared rusted including needle nose pliers.

-The surgical sterile processing room did not contain a hand washing sink and the Steris hand sanitizer had been removed from the container.

-The supply room contained packaged surgical sterile supplies. There was Ultra Concentrate Enzymatic Cleaner that was stored on a shelf within the packages of surgical sterile supplies, including LAP CHOLE KIT's and sterile plastic tubing.

Interview with Staff #12 on 3/29/23 at 2:10 PM confirmed the observations of the completed sterile cycle that contained a metal flat tray with surgical instruments; scissors, retractor, scalpel, and tweezers that were not separated amongst each other. Staff #12 confirmed they were stacked or lying on top of each other on the tray; not allowing the complete disinfection of all sides of the surgical instruments. Staff #12 confirmed there were multiple pairs of scissors that were observed in the closed position and lying on top of each other. Staff #12 stated the surgical instruments should not be placed on a tray, should be separated from each other and the scissors should be in the open position. Staff #12 further stated "we will re-do" this sterile wash cycle. Staff #12 confirmed the hand sanitizer had been removed from the wall because it "was expired" and on back order; further stating they were washing their hands in the sink outside of the sterile processing room. Staff #12 stated the plastic yellow item was a door stopper to keep the door open when housekeeping is cleaning. Staff #12 confirmed the yellow door stopper contained black debris and hair and stated it should not be in the drawer and then placed it on a shelf next to other sterile packaging materials.

Interview with the facility's Nurse Manager/Director of Operation Rooms (OR) on 3/29/23 at 1:50 PM who came to the Sterile Processing Room during the surveyors observations stated she did not oversee the Sterile Processing procedures; that the facility's Chief Nursing Officer (CNO) monitored the sterile processing procedures.
Interview with the facility's CNO on 3/29/23 at 3:35 PM stated she had not overseen the sterile processing procedures; further stating that the Nurse Manager/Director of OR oversees the sterile processing procedures.

Review of the facility's Infection Control- Surgery Sterile Processing last revised 1/2006 and effective 1/2023 revealed the following policies and procedures, in part;
Cleaning/Disinfection: Instruments are first decontaminated chemically, then with a disinfectant, then rinsed.
Instruments: After the instruments are washed, they are packaged and a biosign indicator placed in each package or tray.

Review of the facility's Infection Control - Surgery last revised 1/2006 and effective 1/2023 revealed the following policy and procedures, in part;
Sterile and nonsterile supplies will be stored separately.

Most stainless-steel surgical instruments are intended for reuse and may be processed for sterility again and again. Sterility is usually obtained with steam sterilization.

The entire anesthesia equipment is terminally decontaminated, cleaned or sterilized after each use when reusable components are employed or discarded if single-use components are used.

See OR Policy and Procedure manual for specific policies and/or procedures (endoscope, sterilization, cleaning of OR suite (and equipment), sterile processing, steam sterilization, etc.

Review of the Centers for Disease Control and Prevention at: https://www.cdc.gov/infectioncontrol/guidelines/disinfection/sterilization/sterilizing-practices.html
revealed the following, in part;

All items to be sterilized should be arranged so all surfaces will be directly exposed to the sterilizing agent. Thus, loading procedures must allow for free circulation of steam (or another sterilant) around each item.


26870

Based on observation, interview, and record review the facility failed to provide a clean, sanitary, and safe environment to avoid sources and transmission of infections and communicable diseases. Specifically, observations of the facility revealed the following:

1.) The Medical Surgical area was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases.

2.) The Newborn Nursery was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases.

3.) The Labor and Delivery area was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases.

4.) The 2 patient rooms in the facility, Room 106 and 108 were unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases.

5.) The Rehabilitation Center at facility B was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases.

6.) The surgical services area was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases, and;

7.) The Dietary/Kitchen area was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases.

These deficient practices placed the patients' health and safety at risk for the transmission of infections and/or communicable diseases.

The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Infection Control.

Refer to Tag 1208 for specific evidence and findings.


26870

Based on observation, interview, and record review the facility failed to provide a clean, sanitary, and safe environment to avoid sources and transmission of infections and communicable diseases.

Specifically, observations of the facility revealed the following:

1.) The Medical Surgical area was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases.

2.) The Newborn Nursery was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases.

3.) The Labor and Delivery area was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases.

4.) The 2 patient rooms in the facility, Room 106 and 108 were unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases.

5.) The Rehabilitation Center at facility B was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases.

6.) The surgical services area was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases, and;

7.) The Dietary/Kitchen area was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases.

These deficient practices placed the patients' health and safety at risk for the transmission of infections and/or communicable diseases.

Findings included:

Observations on 3/27/23 at 12:45 PM of the facility with staff #6 revealed the following:

1.) Med/Surg

A) Observations on the medical surgical floor revealed a Hoyer lift HPL700 in the hallway with a dusty base and small stains on the base of the equipment.

B) The nurse's station had laminate missing from the shelf, exposing particleboard, which no longer became a wipeable surface for infection control.

C) there were two computers on wheels (COW) in the hallway which had tape on the desktop with dirty edges and a dusty base. One of the drawers was broken, exposing sharp edges. The base of the COW's was covered with small stains. The desktops of the COW were dusty. The computer screen was dusty with a clear substance running down the screen.

D) Walking from Labor and Delivery to the MedSurg floor, there was a metal doorknob plate attached to the wall, the dry wall was missing around the edges of the metal doorknob plate, leaving a hole.

2.) Newborn Nursery

A) the sink in the newborn nursery had yellow stains around the sink.

B) there was an oxygen pole that had a dusty base.

C) the bathing sink in the newborn nursery. The backsplash at the counter needed sealing.

D) there were four boxes of Nutramigen Hypoallergenic baby formula, each containing 6-2 fluid ounce containers which had expired November 1, 2022

E) at the cabinets, the drawer fronts had tape residue, and tape labels which were peeling up at the corners, which were dirty, and you could not wipe down to disinfect.

F) the Circumcision Room procedure room, attached to the nursery, did not have a usable soap dispenser at the clean sink and no biohazard trash receptacle.

3.) Labor and Delivery Room 2

A) in labor and delivery room 2, the bedside table laminate top, the corner was missing, exposing particleboard, which could not be disinfected.

B) the stirrups on the bed were dirty, with a dried substance that streaked down the stirrups, and never wiped down.

C) a drawer in the room had deep scratches on the front, exposing wood, which cannot be wiped down.

D) a clean sink that was rusty and without running water.

4.) Hallway in Medical Surgical Department

A) Fetal Heart Monitor cart had expired AmnioTest swabs expired 4/30/2022.

B) door frames and wall corners had chipped paint throughout the entire hallway leading to patient rooms

C) nurses' station had a 1inchX.5inch laminate missing from the counter.

5.) Room 106

A) Clean linen cart with clean linens found stored in dirty room

6.) Room 108

A) the window seals in the room were dirty, dusty and dead. Bugs were found on the window seal.

B) the bed that was in the room. The panel was broken and being held by tape. There is no tag identifying the bed as not working.

7.) Laboratory

A) The laminate countertop was missing, exposing particleboard at the keyboard table.

Observations on 3/28/23 at 9:00 AM at Facility B, of the facility's Rehabilitation Center with staff #9 present revealed the following:

8.) Rehabilitation Center

A) in the evaluation room. There was a 1 inch wide 3-inch-long gash in the wall.

B) the COW had a dusty base and covered with a sticky substance.

C) the stepper machine base was dusty and dirty.

D) There was wax spilled on the floor leaving waxy residue, from the Parrafin Wax. The spilled wax was there for two weeks.

E) sports table mat the vinyl is ripped exposing the sponge interior, it was partially covered by tape.

F) there were two elliptical machines that were covered in dust.

G) there was a treadmill that was covered with dust.

H) at the sink there was a plant sitting on an old, yellow paper towel.

I) there was a wheelchair arm that was split exposing foam sponge held together with tape.

J) a picnic table outside at the front door entrance with stained rusted weathered and dirt was embedded into plastic cracks.

Further Observations on 3/28/23 at 1:00 PM of the facility's Surgical Area with staff #15 present revealed the following:

9.) Surgical area.

A) The Pyxis machine was sitting on stainless steel table, which was at one time covered with plastic. The plastic under the Pyxis machine was still visible but was torn and lifted around the Pyxis machine. Any fluid could run under the plastic, would not be able to sanitize.

B) Bay #2 had dust on the suction canister, numerous clumps of dust in the corner of room and on the IV pole.

C) the bedside table in Bay #2, the laminate was lifting off the table, leaving a quarter inch gap. No sealed edges.

D) in the G.I. procedure room, the IV pole base was dusty.

E) a drawer in the G.I. room, the front of the drawer had tape residue, dirty edges. The cabinet door next to the drawer had a hole board through the cabinet door, leaving a hole and exposed particle board.

F) Unsealed Ambubag hanging from the wall in the G.I. room, mask open to air.

G) there was a bathroom in the G.I. procedure room. The floor was very dusty with little pieces of trash. The bathroom floor that meets the G.I. OR room floor, there was a half inch gap between the two floors. The floors were of varied materials. gap. There was dirt accumulation in the gap between the two floors.

H) there were holes in the wall at the bathroom sink.

10.) Facility Kitchen/Dietary

Observations conducted on 03/28/2023 from 10:15 AM to 11:45 AM of the facility's Kitchen area with the Director of Dietary present revealed the following observations:

-The automatic dishwashing machine area had white and brown substance on the walls and floors around dishwashing unit. The Still ventilation unit above the automatic dishwasher had a large amount of rust and the vent inside that cabinet had a black/brown build up inside it.

-The handwash sink near the clean dish area drained slowly and held water in the basin for approximately one minute after water was shut off. It had visible buildup of a white and green substance on the faucet.

-The drying area used for the pots and pans had white build up on the tables and walls. There was an electric cutoff switch/box that had buildup of brown debris. The exhaust vent over the clean dishes that were drying was covered with brown debris.

-The floor tiles and grout were discolored, had buildup of a dark brown/black substance.

-Rust observed on metal corners of doorways.

-Dirt and dust accumulated in floor corners and at base of walls throughout the kitchen area. Areas included walkway, dish cleaning area, food preparation area, food storage area, and tray set up area.

-The metal air conditioning vents for ventilation were dusty.

-The freezer on the back wall had a black/brown sticky substance on the top of the unit.

- Unidentified black and brown debris were noted inside the handles on the gray and white bins used for sugar, beans, and rice storage.

- Expired food items were found in the food store area to include one loaf of bread that was partially used with no expiration date and a born-on date of 2-13-24. A package of tortilla's with an expiration date of 3-3-23.

- Two cans of Milkie evaporated milk were dented compromising the packaging integrity were found in food stores ready for use and not removed from use.

- A food rack had a tray of individual slices of pie that were put into individual containers with an open bucket of cleaning solution and rag on same food rack.

- On the retail food service line there were three uncovered clear plastic containers where service line personnel would store clean serving utensils. These containers had a buildup of black and white spots at the bottoms of the containers.

During an interview on 03/23/2023 at 13:30 AM with the Director of Dietary in the kitchen area of the facility stated, she was hired about a year ago, states the kitchen area is small and she struggles as the director to have enough storage in the area. Administration has told her they have intentions on expanding the kitchen area but has no date for the project. She states it is a struggle to have enough room on food stores shelves to have the daily food stores as well as required emergency food stored separately. Because of this they are stored in the same food stores location, but the emergency food is marked as such and rotated accordingly. Rotation of the food stores and discarding of expired food is the responsibility of the entire kitchen staff. There are no walk-in coolers at the facility. The quality assurance performance improvement (QAPI) focus was on the "timelines" that food was being served to the patients and the "accuracy" of the trays being served to include all items selected by the patient, with no missing items. The Director of Dietary states the Contract Nutritionist comes in at least monthly, and she reviews kitchen area, consults with nutrition plans, and does training for employees. The Director of Dietary reported her job duties as oversight was of the chefs, operations, retail, and patient services and reports to the Chief Executive Office. The Director of Dietary indicated staffing was adequate at this time but when she first arrived, they were short staffed. The Director stated they were supposed to complete detailed cleaning of the walls, ceilings, and vents at least once a month. The floor was to be mopped daily, but deep cleaning of floors was supposed to be done by EVS and they have not been doing this. She states the last time floors were deep cleaned was just as she started, and it was with a pressure washer she believes. She has asked to have the kitchen floors deep cleaned from a professional floor cleaning company and have the grout sealed. She has talked to Infection Control Nurse about the situation, it is her understanding there are no plans to have this done.

During an interview on 03/28/23 at 4:15 PM with Director of Environmental Services (DoEVS) she states that it the responsibility of the Kitchen staff to clean the kitchen areas to include the floor. She states that while she was the interim Director of Dietary about a year ago, she did have the floors pressured washed, but they did not come as clean as she had wanted and got dirty again very quickly afterwards.

During an interview on 05/2/23 at 3:50 PM with the Infection Disease Nurse she stated the Director of Dietary was responsible cleaning the kitchen area of the facility including the floors. She states the kitchen floors, and the cleanliness has been brought to her attention by the director of Dietary, and the need to have a deep cleaned by a professional floor cleaning company. To her knowledge the are no plans to have this contracted out at this time.

The following facility records and policies were reviewed:

Review of the policy titled, Dietary Services dated 01/2023 revealed the following, in part:
2. Dietary Service manager:
-To develop and maintain clean, sanitary work areas, storage areas and equipment for handling of supplies in accordance with state and local health department standards.
3. Infection control Practices
- All floors in the Dietary Services food preparation area will be cleaned daily with approved disinfectant.
-Separate areas shall be specified for food preparation and for cleanup.

Review of the policy titled, Schedule for Cleaning, effective 01/2023 revealed the following, in part:
Daily
-7. Floors in kitchen - Both (Chief and Aid)

Review of the policy titled, Dietary Prevention of Infection, effective 01/2023 revealed the following, in part:
Procedure
G. Environmental Cleaning
1. All environmental cleaning in the dietary area is the responsibility of the dietary personnel.

Record review of the facility policy, titled Infection Control, last revised 05/2020, states in part...
"All healthcare providers, in partnership with the medical staff, are responsible for the safety, health and well-being of all patients, physicians, visitors and healthcare workers (HCW). This responsibility maybe met by working together continuously to promote safe infection control practices, observing all rules, regulations, procedural guidelines and continually assessing the program to identify risks involved with the facility's demography of patients, in an effort to improve the quality of patient care."

Record review of the facility policy, titled General Hospital Wide Infection Control, last revised 11/2001, states in part...
"Equipment and Cleaning of:
Machines: Damp wipe with approved disinfectant daily and PRN by Imaging/Radiology Department personnel.
Exam tables: Wipe with disinfectant between patients by Imaging/Radiology Department personnel.
Furniture, floor, walls, counters, sinks, ceiling tracks, gurneys and wheelchairs: Environmental Services personnel clean floors daily, spot wash or thoroughly clean walls as needed, clean sinks daily, ceiling tracks as necessary, gurneys and wheelchairs when visibly soiled.
Minor spills of blood, body fluid, and/or other potentially infectious material: Imaging/Radiology departmental personnel are to clean minor spills immediately utilizing approved disinfectant and wearing appropriate personal protective equipment.
Major spills of blood, body fluid, and/or other potentially infectious material: Contact Environmental Services personnel to manage major spills."














26870

Based on observations, interviews and record review, the facility failed to ensure that patients received care in a safe setting.

Specifically, the facility's rehabilitation center (facility B) failed to have emergency pull chords for patient safety in the patient's bathroom in the event of a medical event and/or emergency.

The findings were:

Observation on 3/28/2023 at 09:20 AM at Facility B revealed that the patient bathrooms did not have emergency pull cords in the event a patient had a medical event and/or emergency.

Interview on 3/28/2023 at time of observation with staff #9 stated "that he was unsure if pull cords were required."

Record review of facility policy titled, Patient Rights (undated) stated in part, "To a safe, secure, and sanitary accommodation ... ".