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The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See C-231





26222

Based upon observation, interview, and record review the facility failed to maintain the physical facilities and equipment to ensure patient safety.
Findings Include:
On 9/14/10 at 10:40 AM based upon observation, there was no chlorine sanitizer residual in the dishwashing machine in the kitchen, measured with a chlorine test strip. Interview with the Director-Clinical Support Services at 10:40 AM, she stated that she thought the quaternary ammonia test strips were the correct strips to use and that a log was not kept in the kitchen for monitoring sanitizer concentrations.
On 9/14/10 at 10:45 AM based upon observation, there were portioned containers of cream cheese dated 8/25. Based upon interview, these were stated to be preparation dates. Based upon observation, an opened gallon of skim milk was found undated. These items were then observed discarded by a kitchen employee.
On 9/14/10 at 10:45 AM, based upon observation, the ice machine bin and condenser drain lines were observed without the proper air gap.
On 9/14/10 between the hours of 11:20 AM and 1:00 PM, atmospheric vacuum breakers were found to be under constant pressure in the following locations: janitors closets in the OR, X-Ray mechanical room, and patient room areas.
On 9/14/10 at 12:10 PM, the ice machine drain line in the patient pantry was observed to be directly connected to the hand sink drain, located in the cabinet beneath.
On 9/14/10 at 12:40 PM, based upon observation, the Reduced Pressure Principle Backflow Assembly (RPZ) on the main water line into the hospital had a testing tag with a date of 5/12/04. Maintenance Employee#1 was unaware of any test dates beyond that date. Record review confirmed that there were no test results for this assembly.
On 9/14/10 at 10:20 AM, based upon observation the central clean supply room was discovered to have damaged and missing floor tiles beneath the 2 compartment sink.
On 9/14/10 at 12:10 PM the medication room was observed to have peeling paint on the ceiling.
On 9/14/10 at 12:45 PM, the pharmacy countertop edges were observed damaged and repaired using duct tape.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on September 9, 2010, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated September 9, 2010 for Life Safety Code.