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Based upon observation, record review, and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid 42 CFR Subpart 485.623(c), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include:

C-0912 - Failure to ensure that the hospital is constructed, arranged, and maintained to ensure the safety of patients
C-0914 - Failure to maintain correct labeling of the medical gas zone valves
C-0924 - Failure to ensure clean, orderly, and sanitary conditions in the kitchen
C-0926 - Failure to to maintain proper air pressure relationships in the surgery decontamination and sterile storage spaces
C-0930 - Failure to comply with applicable provisions of the 2012 edition of the Life Safety Code

Based on observation and interview the facility failed to ensure that the hospital is constructed, arranged, and maintained to ensure the safety of patients resulting in the potential for with adequate resulting in the increased potential for cross contamination of equipment and utensils, foodborne illness, and transmission of infectious agents to all patients.

Findings include:

On 1/23/2023 at 12:31 PM, the plumbing drain lines on the rinse and sanitizing compartments of the kitchen's three-compartment sink were observed directly connected and terminating into the floor without the presence of air gaps. At this time the surveyor inquired with staff W on if there had been any recent plumbing projects completed on the three-compartment sink, to which they stated, "I'm not sure, but I only have a basic knowledge of plumbing. We also do have a basement where to drains are visible though". On 1/23/2023 at 12:36 PM, upon inspection of the visible drain lines in the basement, the drains lines for the three-compartment sink were identified by both the surveyor and staff W. At this time it was confirmed that all of the three-compartment sink's drain lines were directly connected and without the presence of air gaps for backflow prevention.


43001

On 01/24/23, During the tour of the medical/surgical patient care area at 1435, it was observed that the cross-corridor smoke barrier door separating the offices area and the nurse station for the medical/surgical area had several chips in the face and side of the door. This renders these areas of the door as uncleanable and can harbor infectious diseases. This was confirmed by staff W at the time of observation

On 01/24/23, during the tour of the medical/surgical patient care area at 1442, it was observed that patient room 205 entry way door had several chips on the face and sides of the door. At the time of observation, staff W was asked about the condition of the door they stated that they were updating the life safety drawings for the facility and the doors were going to be addressed as a part of this project.

Based upon observation and interview, the facility failed to maintain correct labeling of the medical gas zone valves in the medical/surgical patient care area. Without proper identification as to area served, the wrong gas valve could be turned off in an emergency resulting in potential serious physical harm to all patients served by that medical gas system zone.
Findings include:
1. On 01/24/23, during the tour of the medical/surgical patient care area at 1413, it was observed that the medical gas zone valve boxes in the nursing station and hallway were labeled incorrectly for the rooms that the zone valve box serves. When staff W was asked why the zone valve boxes were labeled incorrectly, they stated that the rooms were recently renumbered during a renovation and the medical gas zone valve boxes were not updated.

Based on observation, interview and record review the facility failed to ensure clean, orderly, and sanitary conditions in the kitchen, resulting in the increased potential for cross contamination of food, foodborne illness and transmission of infectious agents to 3 patients receiving oral foods.

Findings include:

On 1/23/2023, the following food contact surfaces were observed soiled in the kitchen:

At 10:24 AM, on the blade of the number ten can opener.

At 10:32 AM, on the interior of the microwave. At this time the surveyor inquired with Cook, staff W, as to the current state of the microwave to which they replied, "I haven't used it yet today, and I did not work yesterday, so I'd say the Cook didn't clean it from last night". On 1/23/2023 at 10:34 AM, the surveyor requested the facility's daily cleaning logs from staff W to review to which they replied, "let me see what I can find, I'm not sure if we have any".

On 1/23/2023, the following non-food contact surfaces were observed with an accumulation of dust and debris in the kitchen:

At 10:49 AM, on the walk-in cooler fan grates.

At 11:22 AM, throughout the main ventilation exhaust hood. At this time the surveyor inquired with staff W on the frequency in which they hood is cleaned to which they replied, "I know the filters were just done about two weeks ago, but it doesn't look like the hood was cleaned when they did it. I'll keep my food covered with lids on the stove until we can get this cleaned".

On 1/23/2023 at 11:28 AM, a cleaning log was received by the surveyor from staff W. At this time staff W stated, "this is the most recent cleaning log I could find". On 1/23/2023 at 4:36 PM, record review of a cleaning log dated 4/25/2022 and titled, "Daily Check List" revealed that the facility previously utilized cleaning logs to ensure that daily and frequent cleaning of the kitchen and its equipment occurred.

Based upon observation and interview, the facility failed to maintain proper air pressure relationships in the surgery decontamination and sterile storage spaces, resulting in the potential spread of infectious diseases to all surgical patients. Findings include:
1. On 01/24/23, during the tour of the surgery area at 1314, it was observed that the decontamination room had a positive air pressure relationship with respect to the surgery area corridor by performing the tissue test at the undercut of the door. Staff J was queried at the time of observation if they have noticed this before, they stated that the pressure relationships were not tested regularly.
2. On 01/24/23, during the tour of the central sterile processing area at 1357, it was observed that the sterile storage area had a negative pressure air relationship with respect to the corridor by performing the tissue test at the undercut of the door. This finding was confirmed by staff W at the time of discovery.

Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 485.62(c), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include

See the individually and below cited K-tags dated January 23, 2023.
K-0222
K-0281
K-0324
K-0341
K-0353
K-0761
K-0781
K-0916
K-0917
K-0918