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Based on observation, the facility failed to maintain and operate a properly clean and safe environment. The findings include:

1.During the walk through of the facility on May 22, 2012 it was noticed that heavy and High dusting (dirt/grime) built up on rack/shelves and countertops in lab, emergency room, radiology department, and other patient care areas;
2. Stained and/or missing ceiling tiles are typical in lab, radiology, common corridors, Steris machine room in basement;
3. Heavy dusting build-up on caster wheels in lab area;
4. Rusty and filthy base cabinet under the handwashing sink in the lab area; and
5. The entire hospital does not have the required GFI outlet next to any sink only standard electrical outlet. GFI is required within 6 ft. of water source to minimize the possibility for electrocution when using equipment or device while hand(s) are wet.

The high dusting/dirt and rust conditions do not promote a sanitary condition or proper cleaning environment.

Based on observation, the facility failed to maintain and operate a proper ventilated patient care area. The findings include:

During the walk through of the facility on May 22, 2012 it was noticed that the typical exhaust grille/fan (entire hospital) is not operational and failed all testing when tested. Improper ventilation could lead to infection control issues as well as discomfort to all patients, staff, and visitors.

Based on policy review, medical record review and interview the facility failed to develop a system for identifying, reporting, investigating and controlling infections, which has the potential to spread infectious agents among patients, visitors and staff (C 0278).

The facility also failed to ensure that rehabilitation services were provided in accordance with an individualized plan of treatment with measurable goals for 3 of 5 records reviewed (#19, #22, #23) receiving physical therapy services (C 0281). This is a repeat deficiency from the survey completed in August of 2010.

Based on interview and record review, the facility failed to ensure a system for identifying, reporting, investigating and controlling infections, which has the potential for spreading infectious agents among patients, visitors and staff. Findings include:

On 05/22/12 at approximately 1430 during an interview with staff C it was determined that the infection control program was "not as active as it should be." The only surveillance that staff C has completed was when staff C was assigned to the operating room as a circulating nurse. " I would watch for any cross contamination. I would watch if they were washing their hands or not." Staff C confirmed that there was no documentation to support that the monitoring took place in the operating room and that there was zero (0) monitoring throughout the rest of the hospital.


On 05/23/12 at approximately 1000 during record review it was determined that the facility did not maintain an active surveillance program throughout the CAH that included specific measures for prevention of infections. There were only two meetings documented, "June of 2012 and December 21, 2011" for "Infection Prevention"in the last 6 months. As stated above by staff C, the program was "not as active as it should be."

Based on policy review, records reviewed, and interview the facility failed to ensure that rehabilitation services were provided in accordance with an individualized plan of treatment with measurable goals for 3 of 5 records (#19, #22, #23) receiving physical therapy services. This is a repeat deficiency from the survey completed in August of 2010. The plan of correction received for the August 2010 survey was not implemented. Findings include:

On 5/22/2012 at approximately 1215 during review of the policy entitled; "Implementation of Physical Therapy into Plan of Care", specifies the physical therapist will; "Perform an initial evaluation of the patient including objective data on functional limitations", then develop a plan of treatment that reflects; "Realistic goals will be written in measurable terms."

Medical Record #19: The patient was diagnosed with back pain. The goals identified on the evaluation were as follows; "1) Pain Free, 2) Restore lost function 3) Improve range of motion, 4) Develop a supportive home program". The identified goals failed to be individualized and written in measurable terms.

Medical Record #22: The patient was being treated for neck pain. The goals identified on the evaluation were as follows; "1) Improve pain, 2) Restore lost function, 3) Develop a supportive home program". The identified goals failed to be individualized and written in measurable terms.

Medical Record #23: The patient was being treated for Sciatica pain. The goals identified on the evaluation were as follows; "1) Restore lost function, 2) Improve pain, 3) Develop a supportive home program." The identified goals failed to be individualized and written in measurable terms.

On 5/23/2012 at approximately 0930 the above findings were confirmed with staff B.

Based on observation, the facility failed to maintain and operate a patient and staff safe zone/environment. The findings include:

1. The walls to the converted patient room # 117 into the new C-Arm Room are not shielded subjecting the staff and the patient to radiation every time the C-Arm is in operation. No records is available to indicate when this C-Arm Room conversion took place.

2. The x-ray trigger (knob) in the control cabinet serving the radiology room is loose and can subject the technician to an accidental radiation if held in technician's hand and tech sticks his/her body into x-ray room while talking with patient.