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Based on observation, interview, and record review, the GB failed to ensure the safe and effective operation of the hospital as evidenced by:

1. The GB failed to ensure the medical staff was accountable to the GB for the quality of care and services provided to patients in regard to implementation of ongoing professional practice evaluations (OPPE) for the medical staff. Cross reference to A049.

2. The GB failed to ensure a detailed institutional plan and budget included the operating budget, all anticipated income and expenses, a three-year period of capital expenditures, including in the present year, and sources of financing for planned expenditures in the capital plan. Cross reference to A073.

3. The GB failed to ensure contracted services were evaluated regularly to confirm they provided safe and effective care. Cross reference to A084.

4. The GB failed to ensure a hospital-wide, data-driven, effective QAPI program was implemented and maintained. Cross reference to A263.

5. The GB failed to ensure the facilities and equipment used for patient care were maintained to ensure the safety of patients and staff. Cross reference to A700.

The cumulative effect of these systematic practices resulted in the GB's inability to provide high quality healthcare in a safe environment.

Based on observation, interview, and record review, the hospital failed to ensure a hospital-wide, data-driven, effective QAPI program was implemented and maintained as evidenced by:

1. The hospital failed to ensure the QAPI program collected data and identified opportunities for improvement and change in the physical plant. Cross reference to A283.

2. The hospital failed to ensure the QAPI program maintained an ongoing program and recognized the measurable indicators as opportunities for improvement health outcomes for ED Trauma, Facilities, EVS, and Nutrition Services. Cross reference to A297.

3. The hospital's GB failed to ensure the POCs related to the kitchen was implemented. Cross reference to A309.

4. The hospital failed to ensure adequate resources were allocated to improving and sustaining the hospital's performance of medical equipment due to a credit hold. Cross reference to A315.

The cumulative effect of these failings meant the hospital did not implement and maintain a quality improvement program to ensure the safety and quality of the services provided.

Based on observation, interview, and record review, the hospital failed to ensure facility and equipment used for patient care were maintained to ensure the safety of patients and staff as evidenced by:

1. The hospital failed to conduct the EOC rounding in 2025 as scheduled. Cross reference to A701.

2. The hospital failed to ensure the proper and safe storage and disposal of sharp and pharmaceutical waste. Cross reference to A713.

3. The hospital failed to ensure the facility and equipment were maintained at an acceptable level of safety and quality. Cross reference to A724.

4. The hospital failed to maintain ventilation and humidity levels as per the hospital's P&P. Cross reference to A726.

The cumulative effect of these systemic practices resulted in the hospital's inability to provide quality healthcare in a safe and sanitary environment creating the risk of poor health outcomes for the hospital's patients.

Based on interview and record review, the hospital failed to ensure the medical staff was accountable to the GB for the quality of care and services provided to patients in regard to implementation of ongoing professional practice evaluation (OPPE) for the medical staff. This failure increased the risk for substandard outcomes for patients receiving care from the medical staff.

Findings:

Review of the hospital's Governing Board Bylaws dated 3/28/24, showed

* Section 6.3 showed the Board will delegate to the Medical Staff the responsibility and authority to evaluate all matters relating to medical staff and forward specific recommendations with appropriate supporting documentation for the Governing Board to make an informed decision. The Board will consider the recommendations.

* Section 6.7 showed the Medical Staff will be responsible to the Board for general quality of medical care provided in the hospital. The Governing Board will assure that specific review and evaluation activities are undertaken in order to assess, preserve and improve the overall quality and efficiency of patient care in the hospital. The Governing Board will further assure that the Medical Staff will implement and report to the Board on the activities and mechanisms for monitoring and evaluating the quality of patient care. The Board will support and advise the
Medical Staff's activities for monitoring, reviewing, and appraising the quality of patient care.

Review of the Medical Staff Bylaws dated 11/11/21, 6.3.2 Ongoing Performance Practice Evaluation (OPPE) showed all members are subject to ongoing evaluation based on medical staff peer review criteria. Evaluation results are used in privileging, system improvement and corrective action. Departments will develop and routinely update peer review criteria based on current practices and standards of care. Data will be collected no less frequently than semi-annually on each member. Department Chair analysis will be conducted and reported monthly to the MEC.

During a concurrent interview and record review on 08/25/25 at 1012 hours, with the Director of Medical Staff, the hospital's credential files, and Medical Staff Bylaws were reviewed. The Director of Medical Staff stated the OPPE was reviewed by the department chair, who signed and forwarded it with recommendations to the MEC and the Governing Body, after which the physician was informed of the reappointment status. The Director of Medical Staff stated the OPPEs were not currently being conducted, and the neurosurgery specialty was the only established evaluation created recently. The Director of Medical Staff stated the hospital had approximately 53 medical staff specialties. At present, medical staff performance was assessed through peer references and hospital activity rather than through the OPPE process.

On 08/25/25 at 1330 hours, the above findings were shared with the Interim Administrator, CMO, CQO, and Patient Experience.

Based on observation, interview, and record review, the hospital failed to include a detailed institutional plan and budget to include the operating budget, all anticipated income and expenses, a three-year period of capital expenditures including in the present year, and sources of financing for planned expenditures in the capital plan. This deficient practice had the potential to reduce stakeholder input and accountability regarding prioritization of financial resources.

Findings:

Review of the Governing Board Bylaws dated 3/28/24, showed the Finance Committee shall develop and submit to the Board the budget for the next fiscal year and ensure the implementation of an effective fiscal accounting system.

During an observation, interview, and record review from 8/20/25 to 8/25/25, the hospital failed to ensure the facility and equipment used for patient care were maintained to ensure the safety of patients and staff. Cross reference to A700. No institutional budget or plan was provided on request.

Review of the Medical Equipment Log showed multiple equipment replacement requests in the departments: Surgery, SPD, OR/Trauma, Cardiology, Radiology, and ED.

Review of the Governing Board Meeting Minutes dated 11/25/24, showed the advisement to escalate financial concerns with a letter to corporate by the Board.

Review of the Governing Board Meeting Minutes dated 3/10/25, showed the Chief of Staff requested a letter to corporate leadership emphasizing the need for full visibility into the hospital's financial standing in order to support long-term improvements and sustainability.

On 8/25/25 at 1330 hours, the above findings were shared with the Interim Administrator, CMO, the CQO and Patient Experience.

Based on interview and record review, the GB failed to ensure contracted services were evaluated regularly to confirm they provided safe and effective care. This failure increased the risk that contracted providers were not fulfilling the terms of the agreements and ensuring patient safety.

Findings:

Review of the hospital's P&P titled Annual Contract Evaluation dated January 2024 showed contract monitoring is a key component of contract administration and is imperative to effective enforcement of a contract. The goal is to ensure the contract is satisfactorily performed. A contract will require annual evaluation if a vendor provides a service that can impact patient health outcomes or directly involves the care or treatment of patients in the hospital.

On 8/25/25 at 1109 hours, an interview and concurrent review of facility documents was conducted with the Executive Assistant, the Patient Experience, and the CQO. The Executive Assistant confirmed contract evaluations were not conducted on a known schedule following the departure of the previous CEO who had been responsible for overseeing the evaluations. The Executive Assistant stated there was no transition of the contract schedule when evaluations became due after the CEO left. Typically, the CEO assigned each contract to the appropriate department, which then reported the evaluation back to the CEO.

Review of the contract list showed 267 active contracts. The column listed to show if the contract service agreement was met or unmet for all the listed active contracts, was blank for the entire report.

The Executive Assistant provided three contract evaluations on file, all dated 1/10/24 for a transport service, a medical group, and an ED contract. However, no additional evaluations were provided to demonstrate reviews were conducted during the current year.

The above findings were shared and acknowledged by the Executive Assistant, the Patient Experience and the CQO.

Based on observation, interview, and record review, the hospital failed to ensure the QAPI program collected data and identified opportunities for improvement and change in the physical plant, creating the risk for substandard outcomes for patients in the hospital.

Findings:

Review of the Governing Board Bylaws dated 3/28/24, showed the Quality Management Committee (QM) will objectively and systematically monitor and evaluate safety and risk factors and the quality and appropriateness of patient care, pursue opportunities to improve patient care, and resolve identified problems. The committee will review the Statement of Deficiencies and Plans of Corrections.

During an observation, interview, and record review from 8/20/25 to 8/25/25, the following deficient practices were identified:

* The hospital failed to ensure facility and equipment used for patient care were maintained to ensure the safety of patients and staff. Cross reference to A700.

* The hospital's GB failed to ensure the POC related to the kitchen was implemented. Cross reference to A309.

On 8/22/25 at 1200 hours, an interview and concurrent review of facility documents was conducted with the Vice Chief of Staff, Chairperson, Interim Administrator, CMO and Patient Experience.

Review of the Quality/Patient Safety Council Meeting Minutes dated 3/25/25, showed the Committee reviewed the evaluation of the 2024 dashboard and the proposed plan for 2025. However, the Facilities department had no 2024 goals listed, nor goals for 2025.

Review of the Quality/Patient Safety Council Meeting Minutes dated 6/5/25, showed the Committee reviewed the PI Dashboard and noted there was no data for Facilities Management performance improvement projects as the Director position was vacant.

Review of the Quality/Patient Safety Council Meeting Minutes 7/22/25, showed no facilities data was presented.

The Interim Administrator stated there was a large amount of data which was reported at various meetings as many of the QM topics were moved through committee to committee. However, the challenge was presented with the resignation of key leadership roles related to QAPI in the physical plant. The Interim Administrator stated the systems were fragmented but the Committee was meeting weekly to go over systems and metrics.

The Vice Chief of Staff stated there was a need to create alignment and identify the gaps and action plans as many of the system work was not in alignment.

On 8/25/25 at 1330 hours, the above findings were shared and acknowledged by the Interim Administrator, CQO, CMO and Patient Experience.

Based on interview and record review, the hospital failed to ensure the QAPI program maintained an ongoing program and recognized the measurable indicators as opportunities for improvement health outcomes for ED Trauma, Facilities, EVS, and Nutrition Services. This failure could potentially affect health outcomes and poor quality care.

Findings:

Review of the hospital's Governing Board Bylaws dated 3/28/24, showed the QM Committee will objectively and systematically monitor and evaluate safety and risk factors and the quality and appropriateness of patient care, pursue opportunities to improve patient care, and resolve identified issues. The QM Committee will be responsible for reviewing the written QAPI program and ensuring appropriate resource allocation to ensure proper implementation of the program.

Review of the Organization-Wide Quality Assessment and Performance Improvement program dated March 2024 showed measures for periodic assessment and improvement including problem-prone, high risk, high volume processed and patient safety. The data collection determines root causes, track performance, and benchmarking and will be organized in a way to facilitate comparisons and trends. The Governing Board will approve the program and determine that data collection will be sufficient in detail to provide the user of that data with information to make timely, accurate and data-driven decisions.

Further review showed the aggregation and analysis of data will establish a baseline level of performance, determine the stability and effectiveness of the process, identify opportunities for improvement, and the need for more focused data collection, and determine whether improvement has been achieved or sustained.

On 8/22/25 at 1351 hours, an interview and concurrent review of the Quality/Patient Safety Council Meeting Minutes dated 3/25/25 was conducted with the Patient Experience.

Review of the Quality/Patient Safety Council Meeting Minutes dated 3/25/25, showed the following:

- The Trauma department showed a 2024 goal #1 was to have Trauma closure hours at 0%. However, the goal was not met with a 3.2% occurrence. Goal #2 was to have the Massive Transfusion Activation at 100%, with the goal not met at 92.2%. Goal #3 had a CAGE screening of all admitted trauma patients at 100%, with the goal not met at 81.7%.

However, review of the goals for 2025 showed the comment "Same as 2024, adding more?", and "Do you want to decrease goal of 2%, 80%, 90%, 95% and 100%." Instead of identifying specific action plans to meet the goals, the discussion was to lower the benchmark.

- Review of the Facilities, EVS and Nutrition Service departments failed to have 2024 goals or 2025 goals and metrics discussed.

On 8/22/25 at 1200 hours, the above concern was shared and acknowledged by the Vice Chief of Staff, Chairperson, Interim Administrator, the CMO, and the Patient Experience.

Based on observation, interview, and record review, the hospital's GB failed to ensure the POC related to the kitchen was implemented. This failure created an increased risk of poor health outcomes for the patients.

Findings:

During an observation, interview, and record review from 8/20/25 to 8/25/25, the following deficient practices were identified:

* The hospital failed to ensure the kitchen equipment was maintained in good working conditions. Cross reference to A724, example # 1.

* The hospital failed to ensure the work orders for kitchen equipment were completed. Cross reference to A724, example # 2.

Review of the hospital's POC for the previous CV surveys completed on 2/25/25, showed once a week the Director of the FNS will round the kitchen to ensure ... the kitchen is in good condition, safe working conditions .... equipment is functional and maintained .... Any issues identified will be corrected .... Rounding will be documented and records of reeducation or corrections made will be kept."

Review of the kitchen weekly rounding dated 5/16/25, showed refrigerators 2 D and 9 D, and Box #1 were identified not functioning until July 16, 2025 rounding. On the comment section, there was no annotation that correction was made for the equipment.

Review of the open work orders from May to August 2025 did not show the refrigerators 2 D, 1 D, 11 D, and the portable food warmer heating cabinet were out of order.

On 8/21/25 at 1107 hours, an interview and record review were conducted with the Corporate Director of Facilities and the Lead Central Plant. The Lead Central Plant stated he was not aware that the refrigerators 2 D and 11 D were broken or not functioning, the 1 D refrigerator was reported today, and someone was here now to look at it.

On 8/25/25 at 1255 hours, an interview was conducted with the Lead Central Plant. The Lead Central Plant was asked for the documented evidence of the PM for the refrigerators and freezers in the kitchen. The Lead Central Plant stated the PM for the freezers and refrigerators in the kitchen were not done.

Based on observation, interview, and record review, the hospital failed to ensure adequate resources were allocated to improving and sustaining the hospital's performance of medical equipment due to a credit hold, creating the increased risk of poor health outcomes for the patients receiving services at the hospital.

Findings:

An inspection of the CCU and the ICU was conducted with the Director ICU on 8/20/25 at 1016 hours. One balloon pump, identified as critical patient equipment, was found with an expired preventative maintenance (PM) sticker. A yellow-colored label was affixed to the machine. The label showed "GETINGE" and "PM Due Date 6-2025." The Director ICU confirmed the PM was overdue.

An interview and concurrent review of the vendor PM documentation for five (5) balloon pumps was conducted on 8/22/25 at 1415 hours, with Biomed 3.

Review of the vendor PM documentation showed the last PM for the five balloon pumps was done on 12/20/24. Biomed 3 stated the PM was due semi-annually.

Biomed 3 stated the balloon pumps were in Surgical Services, the ICU, and the Cath Lab, with one balloon pump being a mobile float and another in the Biomed shop.

Biomed 3 stated the vendor had not performed PM on these devices because the hospital had not pre-paid for the service.

Biomed 3 confirmed that the hospital was on a credit hold for $50,000 with the vendor, preventing scheduled PM on the balloon pumps until the amount was paid upfront.

A request was submitted to the Patient Experience on 8/25/25 at 1020 hours, for all documentation and correspondence related to the credit hold and efforts to secure payment. An interview with the Chief Nursing Officer was also requested.

An unsolicited interview with the Director of Perioperative Services occurred on 8/25/25 at 1024 hours. The Director of Perioperative Services stated that Biomed 3 would provide all information regarding the credit hold.
The request to interview the Chief Nursing Officer was re-emphasized.

An interview was conducted on 8/25/25 at 1032 hours, with Biomed 3. Biomed 3 stated that the check request for the credit hold was initiated on 8/22/25.

A request for an interview with the CNO was submitted, and a follow-up request was made. Neither request resulted in an interview with the CNO.

The credit hold documentation requested on 8/25/25, was not provided by the time of the exit conference with the hospital on 8/25/25 at 1330 hours.

Based on observation, interview, and record review, the hospital failed to maintain the physical plant to ensure patient safety when the hospital failed to conduct Environment of Care (EOC) rounding in 2025 as scheduled. This failure posed the increased the risk for substandard outcomes for the patients in the hospital.

Findings:

Review of the hospital's P&P titled Environment of Care Management Plan dated August 2023 showed the environmental rounds process as follows:

- Preparation

- Scheduling: Environmental rounds are scheduled by the Facilities Department. All hospital departments are surveyed during the year; on a minimum, patient care areas are surveyed
bi-annually, non-patient care areas are surveyed once per year.

- Touring and Discrepancies Reports: Departments are notified at the beginning of the month if their unit is scheduled for inspection. Discrepancies identified during the environmental rounds are recorded and entered into a facilities work order database and captured as urgent or routine.

- Discrepancy Resolution: Appropriate action is taken to remedy identified discrepancies and
corrective actions are documented for work order closure. Environmental work orders not completed in a timely manner, are reported at the EOC Committee meeting and the Quality
Council meetings for follow-up

- Trend analysis: Environmental round summary reports are announced at least quarterly in the EOC Committee. Issues found during Environmental Tours are monitored for trends and systemic issues.

During an observation, interview, and record review from 08/20/25 to 08/25/25, the following deficient practices were identified:

* The hospital failed to ensure the facilities and equipment were maintained at an acceptable level of safety and quality. Cross reference to A724.

* The hospital failed to maintain ventilation and humidity levels as per the hospital's P&P. Cross reference to A726.

Review of the environmental rounds 2025 schedule showed 28 patient-care areas were scheduled for EOC rounds bi-annually and 13 non-patient-care areas were scheduled annually.

However, no EOC rounding data for 2025 was provided. And no EOC Committee Meeting Minutes for 2025 were provided.

On 8/20/25 at 1447 hours, the Patient Experience confirmed no EOC rounding was conducted according to the Environmental Rounds 2025 schedule.

Based on observation, interview, and record review, the hospital failed to ensure the proper and safe storage and disposal of sharp and pharmaceutical waste. This failure created the increased risk of unsafe environment.

Findings:

Review of the hospital's P&P titled Biohazard Medical Waste dated 10/1/20, showed all sharps shall be placed in a leak-proof, rigid, puncture-resistant container with the lid locked closed. The container will then be placed in a steritub, segregated from other biohazard waste and the steritub will be labeled "Sharps only."

Review of the hospital's P&P titled Hazardous Materials and Waste Management Plan dated August 2023 showed "Pharmaceutical Waste...EVS or an appropriate service vendor...shall place these containers within the locked area designated and labeled for this purpose located at the basement dock..."

1. An inspection of the CCU and the ICU was conducted on 8/20/25 at 1016 hours, with the Director ICU.

In soiled utility room 3, one sharp container was stored in an unlocked cabinet within a soiled utility room that could not be secured.

The container was found overfilled past the designated fill line. The sharp container was not securely closed with a lid. No designated "Sharps Only" biohazard container (Steritub) was present in the room.

The findings were confirmed by the Director of the ICU.

An inspection of the soiled utility room 3 in the ICU was conducted on 8/21/25 at 1518 hours, with the EVS Supervisor. One sharp container was stored in an unlocked cabinet within a soiled utility room.

The EVS Supervisor confirmed the sharps container was above the fill line and lacked a secure lid. It was stored in an unlocked cabinet, which was accessible from an unsecured room.

The EVS Supervisor stated that sharps containers should be properly disposed of in a designated red biohazard bin. The EVS Supervisor also confirmed that the required "Sharps Only" biohazard container was not present in the room.

2. During a tour of the basement dock on 8/25/25 at 0942 hours, conducted with the EVS Supervisor, one blue pharmaceutical waste container was discovered stored outside of the designated biohazard waste storage area. The container was both unsecured and unattended.

The EVS Supervisor confirmed the improper storage and acknowledged that the container should not have been left unsecured and outside of its proper location.

Based on observation, interview, and record review the hospital failed to ensure the facility and equipment were maintained at an acceptable level of safety and quality as evidenced by:

1. Failure to ensure the kitchen equipment was maintained and in good working condition.

2. Failure to ensure the work orders for kitchen equipment were completed.

3. Failure to ensure trash and cardboard compactors were maintained and in working condition.

4. Failure to ensure the ceiling tiles in corridor to the facilities department and loading dock were maintained in a sanitary condition.

5. Failure to ensure the work order for Rooms B and C was completed.

6. Failure to ensure the Biomedical Engineering implemented the hospital's P&P for Medical Equipment Management Plan. The PM for the ventilator heater and SCD was not completed. The PM sticker posted on the ventilator and BiPAP machine was incorrected. There was no documentation of the equipment inventory list with scheduled PM.

7. Failure to ensure the ED maintained in a safe and functional manner.

8. Failure to ensure the mobile CT unit maintained in a safe and functional manner.

9. Failure to ensure the OR maintained in a safe and functional manner.

10. Failure to ensure the hospital ' s lobby elevators A, B and C maintained in a sanitary manner.

11. Failure to ensure all the fetal monitors had their annual preventative maintenance.

12. Failure to ensure the ICU and CCU maintained in a sanitary and safe manner.

13. Failure to ensure the air conditioning ventilation system in ICU and CCU was maintained.

14. Failure to ensure the work order for the pneumatic tube system in the critical care department was completed.

15. Failure to ensure the PM for balloon pump was completed.

16. Failure to ensure the PM for hospital beds in ICU and CCU was completed.

17. The PM labels for an IV pump showed discrepancies in maintenance and service.

18. Failure to ensure the work order for the nonfunctional code blue buttons in CCU was completed.

19. Monthly rounding by facilities and Biomed was not implemented as per the POC.

These failures created the increased risk of unsafe care to the patients.

Findings:

During a review of the hospital's P&P titled "Medical Equipment Management Plan," dated August 2023, the P&P indicated:

- The hospital conducts environmental tours every six months in patient care areas to evaluate the effectiveness of previously implemented activities intended to minimize or eliminate environmental risks.

- Every 12 months, the hospital evaluates each environment of care management plan, including a review of the plan's objective, scope, performance, and effectiveness.

- The Equipment Maintenance Management/Inventories section showed.

"Inventories...Biomedical Engineering maintains accurate maintenance records (CMMS) of all inventoried medical equipment. Records are electronic, except when hard copy documents are supplied by vendors."

"Preventive Maintenance...equipment is risk assessed into ten categories. Those ten categories make up the Life Support and Non-Life Support groups....Life Support Equipment ... Biomedical Engineering inspects, tests and maintains all life-support equipment and documents these activities in the CMMS. All preventive maintenance activities are to be completed 100% each month. This data is reported to EOC quarterly...Non-Life Support Equipment ... Biomedical Engineering inspects, tests and maintains all non-life-support equipment and documents these activities in the CMMS. Preventive maintenance activities are to be completed 95%, minimally, each month. This data is reported to the EOC quarterly."

* "Preventive Maintenance Procedure ... Biomedical Engineering maintains written maintenance procedures (CMMS) for all inventoried medical equipment ... Biomed technicians review procedures for their accuracy and completeness."

1. During a review of the hospital's P&P titled "9. Maintenance of Equipment" dated February 2014 indicated "The Director of Nutrition Services is responsible for assuring all equipment is maintained in good repair and that all equipment meets all safety and regulatory requirements ... Facilities Department is responsible for the repair and maintenance of all foodservice equipment with the exception of computer equipment ... Nutrition Services is responsible for promptly notifying Facilities Department of any repair and/or maintenance issue through the generation of a work order ... The Facilities Department may authorize Nutrition Services to call vendors to perform work on behalf of the medical center."

During a tour of the hospital kitchen on 8/20/25 at 1000 hours with the Director of RDN and the Kitchen Supervisor, the following equipment was observed to be nonfunctional:

- A large block of ice in the small ice machine bin had pushed a metal component out of place.

- Refrigerator D used for tray line food holding was observed to have a temperature of 48 degrees F. Refrigerator D contained 22 bottles of reduced milk and several cups of pale yellow-beige pudding. No temperature monitoring log was present in Refrigerator D. The Director of RDN stated the milk should be kept at 32 to 41 degrees F.

- 2D Refrigerator had an "out of order" signage posted on the door. The Director of RDN stated the refrigerator 2D1 and 2D2 had been broken for a long time.

- 1D Refrigerator. The Director of RDN stated the refrigerator was also reported as broken for a long time.

- The dishwashing machine was not in use. The Director of RDN stated it had been down since 8/19/25.

- At the cooking area, the portable food warmer heating cabinet was not working. The Director of RDN stated it had been out of service for two months.

- 11D refrigerator was broken.

- Walk-in refrigerator 1 called as dairy refrigerator used for holding food the foe patient's meal, did not have temperature monitoring.

- There was a leak from the ceiling at the cooking area where a hose was connected from the ceiling down to a pile.

Review of the Refrigeration Temperature Log Monthly for Month of August 2025 for 2D Refrigerator showed the temperatures must be recorded a minimum of twice within each 24 hour period; record the temperature as indicated by thermometer on inside the refrigerator; the record refrigerator temperature must be within range between 32 degrees F to 41 degrees F; if the temperature is outside this range, must record corrective action in the comment column. However, further review of the Refrigeration Temperature Log Monthly for Month of August 2025 for 2D Refrigerator did not show the corrective action when the temperature was recorded 60 degrees F in the am and 68 degrees F in the pm on 8/17/25. The comment section showed the refrigerator was out order on 9/17, 8/18, 8/91, 8/20/25.

The Director of RDN was asked about the refrigerators that were not functioning or broken. The Director of RDN stated the kitchen did not need it, the kitchen had enough refrigerator storage, and the hospital census had been low.

2. During a review of the open work orders from May to August 2025, the records did not show the refrigerators 2D, 1D, 11D, and the portable food warmer heating cabinet were out of order.

On 8/21/25 at 1107 hours, an interview and record review was conducted with Corporate Director of Facilities and the Lead Central Plant. The Lead Central Plant stated he was not aware that refrigerators 2D and 11D were broken or not functioning, the 1D refrigerator was reported today and someone was here now to look at it.

Review of the Preventive Maintenance Work Order Work Orders for the Quarterly PM of three upright freezers (F1341, F1344 and F1355) showed the following:

- For the upright freezer F1341, the quarterly PM was active from 5/1/25.

- For the upright freezer F1344, the quarterly PM was active from 5/1/25.

- For the upright freezer F1355, the quarterly PM was active from 8/1/24.

Review of the Preventive Maintenance Work Order for the Semi-Annual PM of the two walk-in freezers (F1336 and F1337) showed the following:

- For the walk-in freezer F1336, the semi-annual PM was active from 11/1/23.

- For the walk-in freezer F1337, the semi-annual PM was active from 11/1/23.

On 8/25/25 at 1255 hours, an interview and record review were conducted with the Lead Central
Plant. The Lead Central Plant verified the above PM Work Orders were not completed.

3. During an observation on 8/20/25 at 1130 hours at the docking area, with the Director of RDN, the Director of RDN stated the "bailer" machine that used to compact the cardboard, had not been used. The machine needed wires to be able to work. The Director of RDN stated the hospital was not in good standing to purchase the wires from the vendor.

At the docking area, a large trash bin was observed overflowing above the rim line. The Director of RDN stated the trash compactor was broken. The trash had been picked up and the Facilities would know how often the trash would be picked up.

Review of the Hydraulic Service for the estimate repair for the compactor dated 3/13/25, showed the estimate was signed on 8/21/25.

On 8/25/25 at 1230 hours, an interview and record review was conducted with the Patient Experience. The Patient Experience stated the staff who requested the work estimate for the compactor did not follow-up.

4. On 8/25/25 at 0935 hours, a tour of the loading dock was conducted with the EVS Supervisor and the Director of RDN. Brown stains were observed on at least 14 ceiling tiles in the corridor leading to the facilities department and loading dock. One ceiling tile with a fire sprinkler was bulging. The Director of RDN stated the stains were from a water leak that had been there for "awhile" and had gotten "worse." The Director of RDN stated the tile with the fire sprinkler was bulging and looked like it was about to rupture.

During an interview on 8/25/25 at 0948 hours, with the Lead Central Plant, the Lead Central Plant stated the leak originating from a steam relief valve on the kitchen's steam kettles had been ongoing for at least one month. This information was unknown to the Director of RDN, who was present during the interview on 8/25/25. The Lead Central Plant further stated that parts had not been ordered as they were still awaiting a quote.

5. During a tour of the Telemetry/DOU unit on 8/20/25 at 1430 hours with RN 2 and RN 3, Rooms B and C in the Telemetry/DOU unit were observed with signs on the doors indicating they were closed. RN 2 stated the rooms had been closed since 8/16/25. There was a repair on the 7th floor that affected Room B and C.

During an interview and record review on 8/21/25 at 1054 hours, with the Corporate Director of Facilities and the Lead Central Plant, the Lead Central Plant stated Rooms B and C were affected by plumbing work being done on Rooms F and G. The work order for Rooms F and G did not include Rooms B and C. The Corporate Director of Facilities stated Rooms B and C were now added to the work order.

6. On 8/20/25, a tour of the hospital units was conducted with RN 2 and RN 3. The following was identified:

- At 1412 hours, in Room A of the medical-surgical unit, an SCD machine was observed with a PM sticker dated 7/22.

- At 1436 hours, in Room D of the Telemetry/DOU unit, a BiPAP machine on standby for patient use at night was observed with a PM sticker dated 11/24. A heater attached to the BiPAP machine had a PM sticker with a due date of 7/25.

- At 1445 hours in Room E of the Telemetry/DOU unit, a patient ventilator was observed with a PM sticker dated January 2005. A heater attached to the ventilator had a PM sticker with a due date of July 2025.

During a concurrent interview and record review on 8/21/25 at 1445 hours, with Biomed 3 and the Patient Experience, Biomed 3 stated the PM for the ventilator was scheduled every year as per the manufacturer's recommendation. Biomed 3 stated the Biomed staff would change the PM stickers after the PM was completed. Biomed 3 showed the PMs for the ventilator and BiPAP machines were completed; however, the stickers on the ventilator and BiPAP machine were incorrect. The Patient Experience stated there was a new P&P for the PM stickers but was unable to provide a copy of it. Biomed 3 stated the PM for the ventilator heater and SCD was scheduled every year; Biomed 3 verified the PMs were past due; however, the SCD was not hospital owned equipment.

On 8/25/225 at 1030 hours, Biomed 3 was asked to show documentation of the equipment inventory list with scheduled PM and the list of stickers used to tag the equipment after the PM was completed. Biomed 3 was unable to show documentation of the equipment inventory list with scheduled PM and the list of stickers used to tag the equipment after the PM was completed.



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7. On 8/20/25 at 1000 hours, an inspection of the ED was conducted with the ED Director and the Trauma Program Director. The following concerns were identified:

- The lobby water fountain's push bar to dispense water was partially broken off and sharp edges.

- Trauma bay 3 had an undercounter cabinet with a broken handle.

The ED Director and Trauma Program Director acknowledged the findings.

On 8/21/25 at 1041 hours, the findings were shared with the Lead Central Plant.

8. On 8/20/25 at 1431 hours, an inspection of the Mobile CT Unit was conducted with the Director of Radiology and CT Technician 1. The following concerns were identified inside the Mobile CT Unit:

- The one hand washing sink was not connected to running water.

- Brown staining marked the ceiling tile above and adjacent to the handwashing sink, and a dried liquid trail extended down the wall to the floor.

9. On 8/20/25 at 1135 hours, an inspection of the OR core was conducted with the Director of Perioperative Services and Patient Experience. The following concerns were identified:

- OR 2's door metal door guard had scattered large dents. Chips in the metal door frame exposed underlying red-stained metal.

- The scrub sink faucet to the left of OR 5 failed to produce warm water after three minutes.

- A large puncture damaged the wall next to the entrance of OR 3.

- OR 3's and 4's outer door had a chipped door guard as well as a chipped door frame.

- Paper and plastic trash was present in the scrub sink near OR 11.

- A puncture damaged the wall in the hallway near the storage room.

The Director of Perioperative Services acknowledged the finding.

10. An inspection of the hospital's main elevators adjacent to the lobby showed the following:

- Elevator A had staining in a liquid spill pattern on the ceiling.

- Elevators B and C had exposed and lifted vinyl flooring at the threshold of the elevator.

11. On 8/20/25 at 1102 hours, an inspection of the L&D was conducted with the Director of Perinatal Services and Patient Experience.

The fetal monitor machine in Room H had a preventative maintenance sticker showing a PM was due on 6/25.

Review of the Preventative Maintenance Work Order forms showed 16 out of 22 fetal monitor machines had their annual PMs on June 2024 and 8/20/25.

On 8/21/25 at 1500 hours, an interview was conducted with Biomed 3. Biomed 3 stated the fetal monitors were on a yearly schedule to have their preventative maintenance.

On 8/25/25 at 1330 hours, the above findings were shared with the Interim Administrator, the Patient Experience, the CQO, and the CMO.


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12. a. An inspection of the CCU and the ICU was conducted with the Director ICU on 8/20/25 at 1016 hours. The following concerns were identified:

* One door near CCU patient Rooms K and L, with keypad access leading to a corridor, was observed to be ajar. The door was labeled from the outside "Authorized Personnel Only." During testing from the corridor, the door was manually opened and closed. On multiple attempts, the door failed to close and latch securely, instead remaining slightly open.

* At the Nursing Station a medical gas cylinder (oxygen tank) was observed to be unattended and not secured in a proper holder.

* In the clean utility room, the following was observed:

- The light fixture on the ceiling contained visible debris. Small objects were noted inside the cover of the light fixture.

- Two metal boxes labeled "TV 1-17" and TV 18-32" mounted on the wall and in between the two boxes an open penetration in the ceiling tile. Tube feeding supplies were observed being stored directly below the non-intact ceiling tile.

- Paint was observed chipping around a wall panel labeled "A6L."

- Cracks and debris on the ceiling tiles, specifically near the air conditioning vent.

- A white, chalky, thick and crusty powdery substance was observed on the wall's surface next to the ice machine.

- Unsanitary and disrepair medical supply carts (including the cart stored immediately outside of the clean utility room). Supply carts had rust, broken parts, were dusty and stained medical tape and/or bandages were improperly used to secure supply bins.

- Visible dust and debris accumulated inside plastic bins containing clean medical supplies and drinking supplies (including water pitchers).

- Damaged, gapped, and/or stained ceiling tiles were observed at the nursing stations and in general unit areas and corridors.

* Three soiled utility rooms were inspection and the following was observed:

- In soiled utility room 1, multiple ceiling tiles were lifted out of place, leaving gaps that provided a direct pathway into the space above the ceiling. The walls in the soiled utility room had drywall damage, with sections completely missing and the internal structure of the wall exposed.

- In soiled utility room 2, the wall was compromised by both physical damage to the drywall and an unsecured opening/access panel.

* In Room I, the following was observed:

- The ceiling tile directly above the air conditioning vent was observed to be lifted and broken.

* In Room J, the following was observed:

- The two poles mounted behind the head of the bed, intended for hanging IV fluids or medications, were observed with multiple areas of rust.

* In Room K, the following was observed:

- The oxygen connector for the patient's oxygen supply was observed secured with multiple pieces of tape. In a concurrent interview the Director ICU stated the oxygen must be "leaking from connection."

- The patient call light was observed to be damaged. The call button was chipped and the cord leading to the call button had multiple strands of exposed electrical wires visible at the point of damage.

- The clip intended to secure the patient call light to the bed linen was observed to be rusty and bent out of shape.

- The non-disposable holder for the suction canister had visible writing on it and tape was observed on the canister. In a concurrent interview, the Director ICU acknowledged the writing likely indicating output measurements from a previous patient.

- The hand washing sink cabinet was found to be unsecure, lacking a proper latching mechanism. Inside the cabinet, multiple mouse and insect glue traps were observed. Multiple brown stains, residue/dust, and visible cracks within the cabinet. Two metal screws were observed sticking out from the cabinet doors.

- The light fixture above the patient's bed was not functioning. Attempts to turn the light on via its pull chain were unsuccessful. The pull chain for the fixture was observed to be so short that it was difficult to access and operate.

- Multiple areas of the countertops had laminate that was peeling and lifting in various spots, exposing the underlying surface.

- A wall-mounted manual sphygmomanometer, intended for taking blood pressure, was observed to be missing its cuff. During a concurrent interview, the Director of the ICU stated the device was non-functional, incomplete as it was missing the cuff and that it should have been removed.

- During inspection of the patient room doors, one door was found to have a sharp, lifted metal strip along the bottom edge. This strip was partially detached and bent, creating a jagged, exposed point.

- The partial countertop or "island" next to the patient bed which provided mounted oxygen, suction, and medical air connections, as well as power outlets, was not in a safe or sanitary condition. The TV mount had visible rust. The TV mounting base remained, but no TV was mounted.

- The ceiling light cover was observed to have orange/brown stains.

* In Room L, the following was observed:

- The partial countertop next to the patient bed had laminate that was damaged, chipped off or broken in multiple areas, exposing the underlying porous surface.

- The hand washing sink cabinet was found to be unsecure, lacking a proper latching mechanism. Inside the cabinet doors, two metal screws were observed sticking out.

- Multiple ceiling tiles were observed to be broken and visible holes in various areas.

- On one of the glass panels of the patient room door a visible crack was observed. During a physical inspection, the surface of the crack was noted to be sharp to the touch.

* In Room M, the following was observed:

- The wall above the head of the bed had a crack and the drywall was damaged.

* In Room N, the following was observed:

- Multiple areas of the countertops had chipped laminate exposing the pressed wood.

* In Room O, the following was observed:

- The TV mount located on the partial countertop next to the patient's bed was observed to be in poor repair. The painted surface was chipped, and areas of rust were visible underneath. The baseboard (hard plastic/rubber material) trim was peeling away from the bottom edge of the partial countertop. The exposure created a gap that showed accumulation of dust, making it difficult to clean/sanitize.

- One chair was observed with a rip on the seat, exposing the internal foam padding.

- The hand washing sink cabinet was found to be unsecure, lacking a proper latching mechanism. The interior of the cabinet was observed to be unsanitary and in disrepair. The cabinet's internal surface had multiple brown stains, visible residue, dust accumulation, and multiple cracks.

b. An inspection of the critical care department continued on 8/20/25 at 1401 hours, with the Director ICU.

* The following was observed in the "neuro" room (4 beds):

- Small pieces of chalky or fibrous materials were found on the sheets at the foot of the bed. The Director ICU stated the debris looked like material from the ceiling tiles.

- Multiple partial countertops were in a state of disrepair. The integrity of both the countertop surfaces and the TV mounts were compromised. The countertops were visibly lifted, creating a gap between it and the base. The base of the TV mount had chipped paint, and visible gaps were present where it met the countertop. The ICU Director stated that the weight of the TV and its mount was possibly causing the countertop to lift and create gaps.

- A handwashing sink was found to be leaking at the base of the faucet when in use.

- Approximately 2 feet of physical damage to the drywall near the floor line, including punctures and gouges. These damages created rough, non-intact surface.

- The cabinet doors below a handwashing sink were damaged and unsecured. The inside of the cabinet was also unsanitary, with cracks, dust, and brown/orange stains or splatters.

- The emergency call light located in the patient bathroom did not have a pull string.

- One computer on wheels had a handwritten note dated 10/09/24, indicating a non-functional scanner.

- Another computer on wheels was found with a work order dated 3/18/25, noting a battery that would not hold a charge.

- A third computer on wheels had a handwritten sign dated 6/29/25, showing the battery was not holding a charge.

- One chair had a handwritten "Broken Do Not Sit" note.

- Another chair had multiple large rips in the seat, exposing the foam padding.

* In Room P, the following was observed:

- The partial countertop has multiple areas with chipped laminate exposing the pressed wood.

* In Room Q, the following was observed:

- One IV pole with rust throughout.

- Door with peeling paint.

- The ceiling light fixture had visible stains and debris inside the transparent cover.

- The partial countertop laminate was cracked in multiple areas. The walls at the base of the partial countertop had physical damage, including holes and chipped paint.

- Countertops with chipped laminate, exposing the porous, pressed wood core beneath.

* In Room R, the following was observed:

- The ceiling light fixture had visible stains and debris inside the transparent cover.

- The light fixture above the patient's bed was not functioning and had multiple stains and debris inside its transparent cover.

- The partial countertop laminate was cracked, with a piece removed and left on the surface. When lifted, it exposed the porous pressed wood core, which had loose pieces that could scatter. The metal frame was bent, and the countertop was visibly lifted, creating a gap. The base of the TV mount (though the TV was absent) had chipped paint and rust. An exposed sharp screw was noted on the base of the TV mount, posing a significant puncture hazard. The baseboard on the partial countertop was cracked and had multiple gaps where it pulled away from the wall. The walls of the partial countertop were damaged, and the paint was peeling.

* In Room S, the following was observed:

- The room door with physical damage including gouges and areas of peeling paint.

- The hand washing sink cabinet was found to be unsecure, lacking a proper latching mechanism. The interior of the cabinet was observed to be unsanitary and in disrepair. The cabinet's internal surface had multiple brown stains, visible residue, dust accumulation, and multiple cracks.

- The base of the TV mount on the partial countertop had chipped paint and rust, and the countertop laminate was cracked. The metal framing that supported the countertop was also lifted, exposing the porous pressed wood core underneath.

* In Room T, the following was observed:

- Damage to the bed footboard's surface, with visible cracks and sections of the material broken off.

* In Room U, the following was observed:

- Damage to the bed footboard's surface, with visible cracks and sections of the material broken off.

- An exposed and sharp screw was found on the window blind pull mechanism for the window.

- The bed had a fitted sheet was damaged with multiple tears.

* In Room ICU A, the following was observed:

- The partial countertop had a crack extending across its entire width.

- Ceiling tiles with multiple brown/orange stains.

- Damage to the bed footboard's surface, with visible cracks and sections of the material broken off.

* In Room ICU B, the following was observed:

- The ceiling light fixture had visible brown and/or orange residue or stains.

- The partial countertop was visibly lifted, creating a gap between it and the base. The metal framing that supports the countertop was also lifted and bent, exposing the porous pressed wood core underneath.

- The light fixture above the patient's bed was not functioning. Attempts to turn the light on via its pull chain were unsuccessful.

- The rubber or hard plastic baseboard on a wall corner was observed pulling away from the wall, creating an unsealed, visible gap.

- A Tram 250SL was observed with a broken or lifted piece of its plastic cover. The device was left on the countertop. There was no work order attached to the device, and the Director ICU was unaware that the Tram was damaged.

13. An inspection of the CCU and the ICU was conducted with the Director ICU on 8/20/25 at 1016 hours. The following concerns were identified:

* Three soiled utility rooms were inspection and the following was observed:

- In soiled utility room 1, the ceiling vent for the air conditioning system was visibly dirty with accumulated dust.

* In Room I, the following was observed:

- The ceiling vent for the air conditioning system was visibly dirty and with accumulated dust.

* In Room J, the following was observed:

- The ceiling vent for the air conditioning system was visibly soiled with an accumulation of dust and a fibrous, hair-like substance.

* In Room K, the following was observed:

- The ceiling vent for the air conditioning system was visibly dirty and with accumulated dust.

* In Room M, the following was observed:

- The ceiling vent for the air conditioning system was visibly dirty and with accumulated dust.

* In Room N, the following was observed:

- The ceiling vent for the air conditioning system was visibly dirty and with accumulated dust.

* In Room O, the following was observed:

- The ceiling vent for the air conditioning system was visibly dirty and with accumulated dust.

An interview with the Corporate Director of Facilities and the Lead Central Plant was conducted on 8/21/25 at 1150 hours, about the findings in the ICU and CCU including the condition of the air conditioning vents.

The Lead Central Plant stated the PM for air conditioning vents should be done semi-annually. The Lead Central Plant stated the PM was not done for the air conditioning vents in the ICU. Documentation for the last PM for the air conditioning vents was requested on 8/21/25 but was not provided by the time of the exit conference with the hospital on 8/25/25 at 1330 hours.

14. An inspection of the CCU and the ICU was conducted with the Director ICU on 8/20/25 at 1016 hours. The following concerns were identified:

- The pneumatic tube system was found in an unsanitary and unmaintained condition. The drop area was covered with multiple layers of chux pads, bed sheets, and other materials. Once these layers were removed, a green-colored egg crate with significant black and brown stains was exposed. The walls surrounding the area showed splash marks of a reddish-brown liquid, and rust was visible on nearby metal surfaces. A posted work order dated 6/2/25 (approximately 2.5 months prior to the survey), noted mold in the carpeted area. The Director ICU confirmed the work order and acknowledged that the sanitation and maintenance problems in the tube system's drop area had been known to the facilities department without correction.

An interview with the Corporate Director of Facilities and the Lead Central Plant was conducted on 8/21/25 at 1150 hours, about the findings in the ICU and CCU including the work order for the pneumatic tube system.

The Lead Central Plant confirmed the work order for the pneumatic tube system dated 6/2/25, for mold in the carpeted area was not addressed.

During an interview and concurrent review of the hospital's P&P titled Work Order Assignment, Priority & Completion dated August 2023, the Corporate Director of Facilities confirmed the work order for the pneumatic tube system was classified as unscheduled non-emergency and that less than 30 days was the established benchmark for the work order.

15. An inspection of the CCU and the ICU was conducted with the Director ICU on 8/20/25 at 1016 hours. The following concerns were identified:

- One balloon pump, identified as critical patient equipment, was found with an expired PM sticker. A yellow-colored label was affixed to the machine. The label showed "GETINGE" and "PM Due Date 6-2025."

16. a. An inspection of the CCU and the ICU was conducted with the Director ICU on 8/20/25 at 1016 hours. The following concerns were identified:

* In Room J, the following was observed:

- The Stryker patient bed had a sticker affixed to the bed and showed the PM was overdue. The sticker specified "Next PM Due 6/24."

* In Room N, the following was observed:

- One Stryker patient bed had a sticker affixed to the bed and showed the PM was overdue. The sticker specified "Next PM Due 6/24."

b. An inspection of the critical care department continued on 8/20/25 at 1401 hours, with the Director ICU.

* The following was observed in the "neuro" room (4 beds):

- The Stryker patient bed had a sticker affixed to the bed and showed the preventative maintenance (PM) was overdue. The sticker showed "Next PM Due 6/24."

* In Room T, the following was observed:

- The Stryker patient bed had a sticker affixed to the bed and showed the preventative maintenance (PM) was overdue. The sticker specified "Next PM Due 6/24."

* In Room U, the following was observed:

- The Stryker patient bed had a sticker affixed to the bed and showed the preventative maintenance (PM) was overdue. The sticker specified "Next P

Based on observation, interview, and record review, the hospital failed to maintain ventilation and humidity levels as per the hospital's P&P as evidenced by:

1. The hospital failed to conduct air balance revalidation testing after failed results in critical patient care areas, including the OR Decontamination Room, ICUs A and B, CATH Labs A and B, and ED Trauma.

2. The hospital did not maintain the humidity levels in the OR as per the hospital's P&P.

These failures increased the risk for substandard outcomes for the patients in the hospital.

Findings:

Review of the hospital's P&P titled Temperature, Humidity and Ventilation Requirement in Health Care Facility dated October 2024, showed

* The hospital follows the 2008 ASHRAE 170 temperature and humidity ranges, air cycle and pressure relationships.

* Functional space requirements:

- The OR has humidity parameters of 30% to 60%.

- The Soiled or Decontamination Room has negative pressurization and a minimum of 6 ACH and exhaust out.

- The Sterile Storage room has a max humidity of 60%.

- The Airborne Isolation Room has negative pressurization and a minimum of 12 ACH.

- The Trauma Room has positive pressurization and a minimum of 15 ACH.

* Engineers will ensure all temperature and humidity changes are reported back to the unit requester. If the equipment is unable to maintain temperature or humidity, the corrective actions taken and the non-compliance information will be reported to the department affected and the facilities manager.

Review of the hospital's P&P titled Air Balance Annual Certification dated August 2023 showed a certified vendor shall test isolation rooms, operating rooms, and identified procedure/sensitive areas at least annually. The results of the test must be documented. Problems found shall be corrected in a reasonable period of time. If the problem(s) prevents the room from providing the standards required, then the room shall not be for that purpose until the condition is corrected.

Review of the Annual Crucial Air Area Validation 2025 dated 4/7/25, showed the following outstanding items:

- The OR Decontamination Room failed to meet ACH and negative pressurization requirements. The space had zero exhaust.

- CATH Lab A failed to meet the CMC for 20 ACH and positive pressurization.

- CATH Lab B failed to meet the ACH requirement.

- ICU A failed to meet the negative space pressurization requirement.

- ICU B failed to meet the ACH and negative pressurization requirements.

- ED Trauma failed to meet the ACH and positive pressurization requirements.

On 8/21/25 at 1129 hours, an interview and concurrent review of the hospital documents was conducted with the Lead Central Plant and the Corporate Director of Facilities.

The Lead Central Plant stated all the necessary repairs were completed internally by facilities with WOs generated on 4/22/25 for OR Decon, CATH Lab A, CATH Lab B, ICU A, ICU B, and ED Trauma. Additionally, on 4/25/25 the Lead Central Plant ordered needed parts for repairs with a contracted service provider making an onsite visit. However, the air balance testing to verify if the rooms were in compliance, was not formally conducted.

The Corporate Director of Facilities stated they wanted to make sure all the readings were correct before having the air balance re-tested again. The Corporate Director of Facilities stated a resolution ideally would be within 90 days with the goal of completing the task as soon as possible.

The Lead Central Plant stated all the rooms were in use except for CATH Lab A, which was under construction.

The above concerns for not timely correcting the above service areas and providing validation testing prior to patient-use per the hospital's P&P were shared with the Lead Central Plant and the Corporate Director of Facilities.

2. On 8/25/25 at 0938 hours, an inspection of the OR was conducted with RN 5, the Director of Perioperative Services, and the Director of Perinatal Services. Humidity readings were randomly checked and out of range for the following ORs:

- OR 3 was at 72.8% humidity level. Staff were present and setting up for a surgical case.

- OR 7 was at 83% humidity level. Wrapped instruments were stored in closed cabinets.

- OR 11 was at 85% humidity level. Wrapped instruments were stored in closed cabinets.

Review of the temperature and humidity logs for August 2025 showed the following:

- ORs 1, 2, 3, 4, 6, 7, 8, 9, 11, the OR Sterile Storeroom and the OR's Inner Core had humidity ranges which had not been documented within the range as 30% to 60% or with a maximum of 60%. "Out of range, Actions Taken" were not consistently documented, nor the "Resolution" of the rooms coming back into a compliant humidity range.

During an interview on 8/20/25 at 1131 hours with the Director of Perioperative Services, the Director of Peri-operative Services stated the ORs had fluctuating humidity levels throughout the day. If the humidity level was out of range, each room could be adjusted in the boiler room with a phone call.

On 8/20/25 at 1441 hours, an interview was conducted with the Lead Central Plant and the Corporate Director of Facilities. The Lead Central Plant stated not knowing how long the
out-of-range humidity in the OR was an issue. Vendors came out previously and determined the reheat coils for each individual room needed to have work done. Additionally, there were
plumbing issues of water leakage onto the reheating coils affecting the humidity as well.

Review of work orders related to the OR humidity showed the internal work order repairs on 11/6/24, with leak testing performed. A plumbing vendor was onsite on 8/5/25 to repair multiple leaks on a pipe related to the reheating coils. No additional service calls or WOs were provided.

The above findings were shared with the Interim Administrator, CQO, CMO and Patient Experience.