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Based on observation, review of policies and agreements, it was determined the facility failed to:
1) Follow their policies for maintenance to prevent an intermittent water leak in the overhead oven vent in dietary and in the clinic.
2) Follow their policies for the removal of biomedical waste.
3) Maintain a sanitary environment in that there were multiple areas of stained and broken ceiling tiles.
4) Follow their procedure for environmental rounds.

The failed practices did not ensure that services would be provided to prevent infection and ensure patient safety. The failed practice was likely to affect all patients, staff and visitors to the facility. Findings included (See C-0278)

Based on observation, review of infection prevention and safety committee meeting minutes, policies and interview, it was determined the facility failed to follow their policies to ensure a safe and sanitary environment for patients and staff in that evidence of water leaks were observed in the dietary department, clinic area, pharmacy, and multiple ceiling tile discolorations in the emergency department hallway, acute care hallway and nursing station. The failed practice did not protect patients and staff from likely sources of infection and had the likelihood of affecting the inpatient census of eight, staff and visitors. Findings included:

A. Review of the facility's policy titled, "Preventive Maintenance," dated 07/24/13, showed the purpose was to ensure equipment was maintained properly and that managers were supposed to fill out a maintenance request online for any malfunctioning equipment.

B. Review of the facility's policy titled, "Infection Control Committee Functions Policy," dated 07/07/14, showed the purpose was to maintain a safe environment for patients and employees.

C. Review of the facility's policy titled, "Infection Control for Dietary," with an effective date of 07/01/07, showed the Consulting Dietitian was responsible for establishing Infection Control practices in the kitchen and the Food Service Manager was responsible for communication of any Infection Control problems to the Infection Control Nurse.

D. Observation on 03/21/19-03/22/19 showed discolored tile and evidence of water leaks in the dietary department (oven vent area), clinic area (ceiling tile black discoloration in one office, one clinic room and over a medication storage cabinet), pharmacy (one ceiling tile), and multiple ceiling tile discolorations in the emergency department hallway, acute care hallway and nursing station. The Maintenance Person #1 confirmed the areas were from previous water damage findings at the time of observation.

E. The Registered Dietitian Consultant Report for the last visit was requested. Review of the Registered Dietitian Consultant Report for 02/27/19 provided by the CDM (Certified Dietary Manager) on 03/22/19 at 12:45 PM, showed no documentation of an intermittent water leak in the overhead oven vent area.

F. The CDM was interviewed on 03/21/19 at 12:01 PM and stated there was a water leak from the stove ventilation area, between a prep table and the stove. The CDM stated it was a steady drip any time it rained hard from the vent area overhead. The drip lands on the floor between the prep table and the stove.

G. The Cook/Dishwasher #1 was interviewed on 03/21/19 at 1:15 PM and stated the water drip started at the screw area of the overhead stove vent. Cook/Dishwasher #1 stated that while it started at the screw, if it rained hard, it would drip in several places onto the floor.

H. Observation of the outer roof surface on 03/21/19 at 12:52 PM above the dietary department showed black painted on areas around the outside of the drain vent. Maintenance person #1 stated on 03/21/19 at 12:58 PM that the ventilation exhaust areas had been painted with something to try to stop the vent from leaking.

I. Cook #2 was interviewed on 03/21/19 at 2:00 PM and stated the last time the roof leaked was a couple of weeks ago. Cook/Dishwasher #1 was interviewed on 03/21/19 at 2:15 PM and stated the last time the vent area in the kitchen leaked was about two weeks ago.

J. On 03/21/19 at 2:10 PM Maintenance Person #1 removed the metal vent intake cover between the stove and prep table in the area of the reported leak. The inner surface of the metal intake cover was observed with areas of rust discoloration and the metal ventilation tube to the roof area had an area of white vertical discoloration along the inside from the upper roof area and extended to the inside and above the area of the reported leak.

K. The Director of Nursing was interviewed on 03/22/19 at 10:08 AM and stated there was no documentation of what had been done to correct the leak from the vent in the dietary department; no monitoring documented to assure it was repaired. Stated she was not able to find any documentation and that she honestly did not believe there was documentation. Stated she had attempted to contact the Maintenance Director but he was on vacation and she had not been able to reach him today.

L. The Director of Nursing was interviewed on 03/22/19 at 11:14 AM and stated she had confirmed with Infection Preventionist and Facilities Manager there was no policy and procedure to replace water stained or damaged ceiling tiles when identified.

M. On 03/22/19 at 1:35 AM the CDM provided documentation that the process they would use if it rained and the leak occurred by the stove was to prepare the cooked food on trays at the steam table where it does not leak. The food trays would then be placed on the serving cart. All of this will be done in the area where there is not a leak when it rains.

N. The CDM was interviewed on 03/22/19 at 9:06 AM and stated she had reported the leaking vent to maintenance many times. Stated she was not aware of what had been done for certain, that she thought they had tried to fix it but it still was leaking with a heavy rain, most recently two weeks ago.

O. The Facilities Manager was interviewed on 03/21/19 and stated he painted over some of the stained ceiling tiles to make it look better and save money for the facility. Stated he did not have tiles to replace them and had ordered them awhile back but had not received them at this time. Stated in order to obtain replacement tiles, he turned in a Non-Stock Purchase Requisition and it had to be approved.

P. On 03/21/19 at 11:49 AM, the Purchasing/Central Supply Manger was interviewed and provided copies of a non-stock purchase requisition for 02/05/19 from the Maintenance Director. Record review of the requisition listed 24 x 48 size ceiling tiles, the reason listed as "We have several tiles broken/stained/ holes that need to be replaced." The Priority level assigned was low. The requisition provided did not have financial approval at the time a copy was provided to Surveyor.

Q. On 03/21/19 at 11:49 AM, review of a non-stock purchase requisition dated 10/31/18 for replacing/repairing the roof over the Administrator's office and dated 11/01/19 for the clinic showed an estimate for repair. Maintenance Person #1 and the Director of Nursing confirmed on 03/22/19 at 10:40 AM, the roof repair/replacement had not been performed.

R. On 03/21/19 the Infection Prevention and Control and Safety Committee Meeting minutes were reviewed with the Director of Nursing and Infection Preventionist. In the 11/01/18 meeting the safety discussion included new business and that areas of mold had been discovered in the Board Room, the Clinic and that pricing for repairs was being researched. There was also discussed that a leak was reported in the kitchen by the stove. The note stated (Named) was to check on this. The Committee Meeting minutes for 02/27/19 showed in old business that the mold in the clinic and board room was removed and was cleaned appropriately. Under new business a quote for roof was turned in to Corporate and a building inspections was to be done in the near future. There was no documentation regarding the status of the leak by the stove in the kitchen.

S. On 03/22/19 at 10:15 AM the Director of Nursing stated Infection Prevention responsibilities had recently changed to a different individual and the Infection Prevention rounds with maintenance and housekeeping had honestly not been done in a while. Documentation of the result of the Infection Prevention Rounds was last documented with the Quality Assurance and Performance Improvement Committee report for 06/19/18.


Based on observation, review of medical waste documents and interview, it was determined the Facility failed to follow their policy to assure a sanitary environment was maintained in that biohazard medical waste was allowed to accumulate and was not collected and removed. The failed practice resulted in the accumulation of 33 biomedical waste containers and 7 sharps bins in the biomedical waste storage area of the facility. The failed practice was likely to affect the census of eight patients and all staff of the facility. Findings included:

A. Observation of the biohazard medical waste storage room at the back of the facility with Housekeeper #2 on 03/21/19 at 2:55 PM showed 33 large medical waste storage boxes and seven 17 gallon rigid sharps containers. By interview, Housekeeper #2 stated the company usually picked up the biohazard waste one time a month but it had been awhile.

B. Review of documentation of the biohazard medical waste pick-up provided on 03/21/19 at 3:28 PM by the Director of Nursing showed the last biomedical waste collected from the facility was 01/02/19. The Director of Nursing confirmed this was the most recent pick up by the biomedical waste company and stated there were payment issues.

C. The Controller for the facility was interviewed on 03/21/19 and provided documents that showed the last payment to the biomedical waste company was on 03/01/19 and was for unpaid invoices from 11/30/18 and 07/31/18.

D. On 03/22/19 at 12:00 the Housekeeping Manager was interviewed and stated she had just checked and the biohazard medical waste had still not been picked up and there was an odor.



Based on observation and interview, it was determined the facility failed to ensure a sanitary environment and prevent likely sources of infection in that ceiling tiles were not inspected and replaced after water leaks. Ceiling tiles with black discoloration in the acute care hallway did not ensure patients, visitors and staff would be protected. The failed practice did not ensure a sanitary environment and was likely to affect all patients, staff and visitors.

A. Observation on 03/21/19 from 12:39 PM - 2:15 PM with Maintenance Person #1 showed four areas on the acute hallway in which ceiling tiles were observed with black discoloration on the back of the ceiling tiles. Maintenance Person #1 removed tiles and the following are examples of black discoloration observed on the back side of each tile on the Acute Care hallway:
1) Two ceiling tiles removed for observation near an exit sign on the north side of the hallway near acute care with black discolored area. This was confirmed at 12:59 PM by Maintenance Person #1, Nurse Manager of acute care and Emergency Department, and Infection Control Nurse #1.
2) Three ceiling tiles removed for observation on the south side of hallway at 1:08 PM. One of three ceiling tiles removed near an exit sign observed with an approximately seven inch area of black discoloration. The observation was confirmed by Infection Control Nurse #1 and Maintenance Person #1 at 1:08 PM.
3) Two ceiling tiles removed on the east side of the acute care hallway at 1:15 PM near the exit sign. There was black discoloration on the back of each tile. This was confirmed at 1:15 PM by the Nurse Manager and Maintenance Person #1.


Based on observation, review of Infection Prevention and Safety Committee Meeting minutes, policies and interview, it was determined the facility failed to follow their policies to ensure a safe and sanitary environment for patients and staff in that ceiling water leaks were not repaired in dietary and the clinic area; stained and broken ceiling tiles were not replaced; biohazard medical waste was not removed to prevent an accumulation; and environmental rounds were not documented and reported to identify and control likely sources of infection. The failed practice was likely to affect all patients, staff and visitors. Findings included:

A. Review of facility policies on 03/21/19 showed:
1) The policy titled, "Preventive Maintenance," dated 07/24/13, showed the purpose was to ensure equipment was maintained properly and that managers were supposed to fill out a maintenance request online for any malfunctioning equipment.
2) The policy titled, "Infection Control Committee Functions Policy," dated 07/07/14, showed the purpose was to maintain a safe environment for patients and employees.
3) The policy titled, "Infection Control for Dietary," with an effective date of 07/01/07, showed the Consulting Dietitian was responsible for establishing Infection Control practices in the kitchen and the Food Service Manager was responsible for communication of any Infection Control problems to the Infection Control Nurse.

B. Observation on 03/21/19 from 8:26 AM - 10:11 AM showed the following:
1) Multiple stained and discolored ceiling tiles observed in the acute care hallway, emergency department, pharmacy (one ceiling tile). Three cracked ceiling tiles observed in the area of the Emergency Department hallway, beside the nursing station and trauma area.
2) Circular hole, approximately three inches in diameter observed in one of the the ceiling tiles of room 201 and one ceiling tile in room 202.
3) Room 104 on behavioral health observed at 9:41 AM with 14 overhead ceramic tile missing in the shower area.
4) Clinic area, Room #3 had an area of black discoloration in the upper corner of one wall, approximately 12 inches in length.
5) Clinic area, one office on same hallway as Room #3 had and area of approximately 10 inches in length of black discoloration on the upper corner of one wall.
6) Clinic area, above a medication cabinet, an area of approximately six inch length of black discoloration in the upper corner along one wall.
All findings in B. 1 - 6 were verified on 03/21/19 at the time of observation by the Nurse Manager of Emergency Department and Acute Care and Maintenance Person #1.

C. Observation of the biohazard medical waste storage room at the back of the facility with Housekeeper #2 on 03/21/19 at 2:55 PM showed 33 large medical waste storage boxes and seven 17 gallon rigid sharps containers. The findings were verified at the date and time of observation.