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Based on observation and interview, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients, staff, and visitors.

Findings:

In an observation on 10/24/2022 at 10:30 a.m. of the hospital with S1Adm, S3Qual, and S4PO revealed the following:

Room "a": There was a hole in the sheetrock with peeling paint in one corner above the shower.

Room "i": White dry erase board and office chair stored in this room.

Room "j": 3 mops, 3 mop buckets, floor cleaner machine, and a floor buffer stored in this room.

The handrails throughout the hallway had numerous areas of peeling paint.

S1Adm, S3Qual, and S4PO, present with surveyor during the observation, verified the above stated findings.

Based on record review, observations and interviews, the infection control officer failed to ensure the hospital's system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel was implemented. This deficient practice was evidenced by the hospital failing to maintain a sanitary environment.

Findings:

Review of the hospital's policy titled, "Environmental Services Cleaning Guidelines" revealed in part, facility shall provide the necessary services required to maintain a clean, sanitary, and safe environment in accordance with industry best practices.

In an observation on 10/24/2022 at 10:30 a.m. with S1Adm, S3Qual, and S4PO revealed the following:

Room "a": Rust was observed on the fire sprinklers above the 2 showers and were unable to be disinfected. Rust was also observed on the lock hinges of 2 storage cabinets and were unable to be disinfected. There were 3 of 4 screw-heads on the paper towel dispenser that had rust on them.

Room "b": Rust was observed on the lock hinges of 2 storage cabinets and were unable to be disinfected. There were 3 of 4 screw-heads on the paper towel dispenser and 6 of 6 screw-heads on the soap dispenser that had rust on them.

Room "c": One table had an area of particle board showing on the edge of the table top and was unable to be disinfected. Rust was observed on the base of this same table where there was missing paint and was unable to be disinfected. Rust was also observed on the lock hinge of the refrigerator and was unable to be disinfected. Numerous dead bugs could be seen in the light fixture above the tables.

Bathroom that was shared by rooms "d" and "e": Numerous dead bugs in light fixture.

Bathroom that was shared by room "f" and "g": Numerous dead bugs in light fixture.

Room "h": Numerous dead bugs in light fixture.

S1Adm, S3Qual, and S4PO, present with surveyor during the observation, verified the above stated findings.