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Based on observation, document review, and staff interview it was determined the facility failed to ensure that facilities were maintained to ensure the safety of patients. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 16.

Findings include:

Document review on 08/14/23 at approximately 1:18 p.m., revealed a wall mounted commercial dehumidifier in the Kingwood Aquatic Therapy Site, which had not received routine inspection or was included in the Hospital's Preventative Maintenance Program.

Observation on 08/14/23 at approximately 1:52 p.m., revealed clean patient supplies, which were stored in the same room as trash and dirty linen in the Milestone Primary Care Office.

Observation on 08/14/23 at approximately 2:07 p.m., revealed cracked and broken floor tile in the Public Restroom near the Lab in the Milestone Primary Care Office.

Observation on 08/14/23 at approximately 2:18 p.m., revealed torn and exposed upholstery on exam tables in Exam Room 2 and Exam Room 4 in the Milestone Primary Care Office.

Interview on 08/14/23 at approximately 2:19 p.m. with the Practice Administrator verified these findings. These findings were also acknowledged by the Chief Administrative Officer at the exit interview on 08/16/23 at approximately 3:36 p.m.

Based on document review and staff interview it was determined the facility failed to maintain a preventive maintenance program to ensure the safe operation of all mechanical, electrical, and patient care equipment. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 16.

Findings include:

Document review on 08/15/23 at approximately 11:39 a.m., revealed the equipment maintenance program was not based off of manufacturer recommendations or other generally accepted standards of practice for an alternate maintenance schedule.

Interview on 08/15/23 at approximately 11:40 a.m. with the Facilities Manager verified this finding. This finding was also acknowledged by the Chief Administrative Officer at the exit interview on 08/16/23 at approximately 3:36 p.m.

Based on document review and staff interview it was determined the facility failed to ensure proper ventilation in patient care areas. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 16.

Findings include:

Document review on 08/15/23 at approximately 11:12 a.m., revealed no documentation was provided during survey to show that the monitoring of the appropriate air pressure relationships for the Laboratory, Operating Room 1, Operating Room 2, Endoscopy, or Sterile Storage had been completed during the previous twelve (12) months.

Interview on 08/15/23 at approximately 11:13 a.m. with the Facilities Manager verified this finding. This finding was also acknowledged by the Chief Administrative Officer at the exit interview on 08/16/23 at approximately 3:36 p.m.

Based on observation, document review, and staff interview, the facility failed to provide safety from fire and meet the provisions applicable to Existing Healthcare Occupancies of the 2012 edition of the Life Safety Code of the National Fire Protection Association (NFPA) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 16.

Findings include:

In reference to Federal Life Safety Code citation K 374 the facility failed to ensure that fire barrier and smoke barrier doors were appropriately constructed and maintained.

In reference to Federal Life Safety Code citation K 511 the facility failed to ensure that electrical wiring and equipment were appropriately inspected and maintained.

In reference to Federal Life Safety Code citation K 781 the facility failed to ensure that portable space heating devices used accordingly in health care occupancies.

In reference to Federal Life Safety Code citation K 914 the facility failed to maintain and test electrical receptacles at patient bed locations.

Interview on 08/16/23 at approximately 1:03 p.m. with the Facilities Manager verified these findings. These findings were also acknowledged by the Chief Administrative Officer at the exit interview on 08/16/23 at approximately 3:36 p.m.