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Based on observation and interview with staff, the facility failed to ensure that the radiology department, surgery, and the kitchen were clean and orderly.

Findings were:

A tour of the CT room in the radiology department was conducted the afternoon of 6/15/10. There were 3 stained ceiling tiles observed. This was verified during the tour by the Assistant Director of Nursing.

A tour of the surgery department was conducted the afternoon of 6/15/2010. A ceiling tile was missing. This was confirmed by the director of surgery during the tour of the department.

A tour of the kitchen was conducted the afternoon of 6/15/2010. The walls were nicked in several areas and in need of fresh paint. The bumper strips were worn down to bare wood and in need of sealing, and there were stained ceiling tiles. This was confirmed during the tour by the director of dietary services.

Based on observation and interview with staff, the facility failed to ensure that drugs were stored in the surgery department in accordance with accepted professional principles, as mislabeled drugs were available for patient use.

Findings were:

Observation of the anesthesia cart was conducted during a tour of the surgery department the afternoon of 6/15/2010. Noted in the cart were two 6cc syringes with liquid in them. The labels on the syringes indicated that the liquid was " succinyl. " There was no indication when the medication was placed in the syringes, by whom, or the strength of the medication which was available for patient use. This was confirmed during the tour by the director of surgery.

Based on review of records and interview with staff, the facility Chief Executive Officer (CEO) failed to ensure that rehabilitation services furnished in the CAH complied with all applicable standards for the contracted services.

Findings were:

Review of the policy and procedure notebook of the facility rehabilitation services was conducted. The facility contracts with the rehabilitation service; however, has not approved the policies and procedures. This was verified in an in-person interview conducted with the facility CEO on 6/16/2010 in a facility conference room.

Based on review of records and interview with staff, the facility failed to ensure that annual program evaluation included review of the CAH ' s healthcare policies.

Findings were:

Review of the facility policy and procedures revealed that none of the policies and procedures had been reviewed annually; for example, the Swing Bed policy manual was last approved in 2008. This was verified in an in-person interview with the facility Director of Nursing (DON) on 6/16/2010 in a facility conference room.

Based on review of records and interview with staff, the facility failed to ensure that the quality assurance program evaluated all services provided by the hospital, as the contracted rehabilitation services were not evaluated.

Findings were:

Review of the facility ' s QA plan and documented activities revealed that the contracted rehabilitation services were not included in the program ' s evaluations. This was verified in an in-person interview with the director of the quality improvement department on 6/16/2010 in a facility office.