HospitalInspections.org

Based on a tour of the facility and an interview with staff, the facility failed to maintain a premise that was clean and orderly.

Findings were:

During a tour of the kitchen on 4-16-25, the following was noted:
* The formica-topped utility table contained numerous areas of chipped/missing/broken formica finish, leaving the porous plywood underside exposed. This underside cannot be adequately cleaned and can harbor bacteria.

* 4 portable fans were being used to circulate air in the kitchen. Portable fans cause dust and debris to become airborne, potentially contaminating food that is being prepared.

* 2 of 2 commercial ovens were dirty and caked with what appeared to be splattered grease and food. In an interview with staff #21 (Dietary Director) on 4-16-25, staff #21 stated that the ovens were too hot to clean and remained hot to the touch at all times.\

* A formica-covered shelf contained areas of missing and worn-through finish, exposing the plywood underneath and preventing the surface from being adequately cleaned.

The above was confirmed in an interview with the CEO and other administrative staff on the afternoon of 4-16-25.

Based on a review of documentation and an interview with staff, the facility failed to make sure the staff were appropriately certified in CPR, when required by their job description.

Findings were:

During the review of personnel files on 4-16-25, personnel files for 4 laboratory staff (staff #23-#26) were examined. The job description for the laboratory personnel required current certification in cardiopulmonary resuscitation. None of the 4 staff held the required cardiopulmonary resuscitation, which was confirmed with staff #6 (HR Specialist).

The above was confirmed in an interview with staff #1 and other administrative staff on the afternoon of 4-16-25.

Based on a review of credentialing files, facility documentation and an interview with staff, the facility failed to provide emergency care necessary to meet the needs of its inpatients and outpatients, as 1 of 2 emergency room, mid-level providers did not possess the appropriate certifications as required of ER physicians by the facility's CEO.

Findings were:

In an interview with staff #1 on 4-14-25, providers that work in the emergency department are required to hold current certification in the following:
* PALS (pediatric advanced life support)
* ACLS (advanced cardiac life support)
* BLS (basic life support)

The credentialing files for 2 ER mid-level providers were reviewed (staff #11 & #12). Staff #11 held current appointment as Active Status to provide emergency services for the facility. Staff #11's BLS, ACLS AND PALS certifications had been obtained through an online testing company, which required no in-person, return demonstration of skills.

Review of the Health & Safety Institute and the National Safety Council website found at http://news.hsi.com/onlineonlycpr reveals that, "No major nationally recognized training program in the United States endorses certification without practice and evaluation of hands-on skills. According to the Occupational Safety and Health Administration (OSHA) online training alone does not meet OSHA first aid and CPR training requirements." Further guidance can be found at https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=28541.

The above findings were confirmed with the facility CEO on 4-14-25, who concurred that staff #11 were not in possession of the certifications required by the facility.