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Based on observation and interview, the facility failed to maintain the physical plant and patient equipment resulting in the potential for less than optimal outcomes and harm in the event of a fire to all (3 in-patients, 1 swing bed patients, 2 observation patients, 1 emergency department patient, and 4 rehabilitation) patients that were currently being served by the hospital. Findings include:

See specific tags:

C-225: Failure to maintain the environment and patient equipment
C-231: Failure to comply with applicable provisions of the 2012 edition of the Life Safety Code

Based on observation and interview, the facility failed to maintain the facility and patient equipment in a clean and well-kept fashion resulting in the potential for spread of infectious agents to the 3 in-patients, 2 observation patients, 1 swing bed patient, 1 emergency department patient, and 4 rehab patients that were currently being served by the facility. Findings include:

On 4/15/2019 at 1054, the Central Supply area was entered and found to have a long crack in the back cinder block wall running from above the pipes overhead to the floor. Additionally, there were multiple concrete anchors which had been screwed into the wall that had caused some damage to the area surrounding them. This was confirmed by Staff C and Staff F at the time of discovery. On 4/15/2019 at 1058, Staff F stated a work order had been made for wall repairs. Despite an initial request for the work order, a second request on 4/15/2019 at 1215, and a third request made by the engineer on 4/16/2019, the work order was not produced prior to the exit of survey.

Room G-020, a storage area, was entered on 4/15/2019 at 1100 and was found to have a missing ceiling tile and wires hanging from the ceiling. This was confirmed by Staff C at the time of discovery. On 4/16/2019 at 1100, Staff C stated that work had been recently done on telephone lines, but he was unsure if the wires coming from the ceiling were telephone wires.

While walking down the hallway on 4/15/2019 at 1115, the door frame for Room G-015 was pulled away from the wall leaving a gap present in the upper left corner. Additionally, veneer was missing off the top of the door exposing the underlayment. These findings were confirmed by Staff C at the time of discovery.

On 4/15/2019 at 1124, in the hallway outside of the storage area, which was across from the dishwashing area and just before an exit to the docking area, the ceiling tile grid was observed to be rusty. This finding was confirmed by Staff C at the time of discovery.

On 4/15/2019 at 1132, a storage area containing oxygen tanks was entered and found to have a strong foul odor present. It was noted that there were no drains in the floor. Three of the four concrete walls in the room had been repaired with a concrete patch which had not been sealed. These findings were confirmed by Staff C at the time of discovery.

On 4/15/2019 at 1140, the area inside of G-041 was observed to have multiple holes in the concrete walls. This finding was confirmed by Staff C at the time of discovery.

Just before entering the door at G-078 on 4/15/2019 at 1141, the flooring was observed to have a large hole present. This finding was confirmed by Staff C at the time of discovery.

The rehabilitation area was entered on 4/15/2019 at 1145 and was found to have a tear in the vinyl of the back pad on the abdominal machine and a piece of vinyl that was missing from a massage chair exposing the foam underneath. Additionally, the pulley machine had a copious amount of paint chips which were missing from all over the unit. These findings were confirmed by Staff C and Staff L at the time of discovery.

The lab was entered on 4/15/2019 at 1200 and was found to have some laminate missing from the cupboard. Additionally, in the blood bank, the ceiling grid and vent were observed to be rusty. These findings were confirmed by Staff B at the time of discovery.

In emergency department (ED) Room 21 on 4/15/2019 at 1400, some laminate was observed to be missing from the cabinet and some wall damage was present exposing the drywall plaster underneath. These findings were confirmed by Staff C at the time of discovery.

On 4/15/2019 at 1402 in ED Room 33, the wall by the trash can was observed to have a deep gouge present at the height of the top of the trash can. Additionally, the caulk around the sink appeared cracked and pulled away from the wall. These findings were confirmed by Staff B at the time of discovery.

In the ED Medication Room on 4/15/2019 at 1406, the cabinet on the end near the phone was found to have cracked laminate. This finding was confirmed by Staff B at the time of discovery.

On 4/15/2019 at 1423, ED Room 1 was entered and found to have wall damage at the level of the top of the visitor chairs in the room. There was also wall damage which exposed the brown paper underlayment of the drywall on the wall that was to the left of the head of the bed, and paint that was cracked and chipping near the oxygen port in the wall. These findings were confirmed by Staff C at the time of discovery.

On 4/15/2019 at 1427, the mammogram room was entered and found to have paint that was peeling near the hand sanitizer dispenser. This was confirmed by Staff B at the time of discovery.

On 4/15/2019 at 1452, Patient Room #227, identified by Staff Q as a patient-ready room, was entered and found to have chipped paint behind the toilet and a thick build-up of caulk between the wall the the baseboard behind the toilet. There were also deep gouges in the bathroom door which exposed the wood underlayment. These findings were confirmed by Staff C at the time of discovery. Staff H stated on 4/15/2019 at 1455 that the whole patient care unit was in the process of a 3-phase renovation and they were currently on the first phase.

On 4/16/2019 at 0933, the isolette for emergency deliveries was visualized. It was observed that the storage area for the isolette had wall damage which exposed the brown paper of the drywall at the approximate height of the top of the isolette. This finding was confirmed by Staff C at the time of discovery.

Facility Job Description for "Maintenance Mechanic I" last revised 12/1/2016 states: "Position Summary: The Maintenance Mechanic performs preventive maintenance, troubleshoots, diagnoses, and repairs mechanical systems and equipment for the facilities."

Facility Job Description for "Facilities Technician I" last revised 1/16/2017 states: "Position Summary: The Facilities Technician 1 performs routine maintenance or facilities related duties to ensure that the facility and property are clean, safe, secure and functioning at optimum efficiency."

Facility Job Description for "Facilities Technician II" last revised 1/16/2017 states: "Position Summary: The Facilities Technician II performs routine maintenance duties throughout the facilities assigned...are also responsible to complete assigned safety checks and adhere to all safety regulations and practices."


30988

On 04/15/2019 at 1100 the Central Supply storage room was entered. The floors were littered with scattered debris, and dirt. The overhead ceiling had multiple pipes crossing the room, the pipes were covered with heavy dust. The finding was confirmed with staff C at the time of discovery. Staff C was asked who was expected to keep the floors and pipes clean, he stated "I think housekeeping."

On 04/15/2019 at 1125 room G-013 a receiving dock for the kitchen was entered. Paint chips on the door and the jamb around the door revealed the metal and wood underneath. Multiple holes in the walls 1/2 to 1 inches were open and un-repaired, the floor was covered with dirt and heavy debris, an old non-working heater located on the left wall by the exterior doors was rusty/corroded/heavily covered with dust. The finding was confirmed with staff C at the time of discovery.

On 04/15/2019 at 1135 room G-057 was entered. The entrance door was noted to have had the hinges replaced, there were 9 old holes that were open and un-repaired. The finding was confirmed with staff C at the time of discovery.

On 04/15/2019 at 1148 the rehab area was entered. The hand washing sink area next to room C-022 had 3 open un-repaired holes just above the sink area. The finding was confirmed with staff C at the time of discovery.

On 04/15/2019 at 0250 room 2-023 was entered. Holes in the wall had been repaired with a dry porous substance but it had not been sealed. The finding was confirmed with staff C at the time of discovery.

On 04/16/2019 at 1030 the reprocessing clean room was entered. The wall hanging cabinets were found to have an accumulation of desk on top. This was confirmed by staff AA at the time of discovery.

On 04/16/2019 at 1100 the utility room on 2 North was entered. An area of paint behind the sink was missing and the area was not cleanable. This was confirmed by staff AA at the time of discovery.

On 04/16/2019 at 1130 the Medication room in the Emergency Department was entered. The shelves had an accumulation of dust on top. This was confirmed by staff AA at the time of discovery.

On 04/16/2019 at 1130 the Medication room in the Emergency Department was entered. Clean supplies were being stored less than 3 feet from the hand wash sink. This was confirmed by staff AA at the time of discovery.

On 4/16/2019 at 1000 the kitchen was entered. The following items were observed:

The floor under the chest-type freezer had no tile under and round it. The floor was concrete and not cleanable. This was confirmed by staff AA at the time of discovery.

The baseboard, located beside the chest-type freezer, was peeling off. The glue holding it to the wall was very sticky and collecting dust and debris. This was confirmed by staff AA at the time of discovery.

The floor located beside the oven was concrete and had no tile surface. This area was not cleanable. This was confirmed by staff AA at the time of discovery.

The floor below and around the steamer had an accumulation of dust and debris. This was confirmed by staff AA 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 patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 485.623(d), 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. Findings include

See the K-tags on the CMS-2567 dated 4/15/2019, for Life Safety Code.

K-0211
K-0225
K-0321
K-0345
K-0346
K-0353
K-0354
K-0363
K-0523
K-0920

Based on observation, interview, and document review, the facility failed to maintain a clean and sanitary environment resulting in the potential for spread of infectious agents to the all (3 in-patients, 2 observation patients, 1 swing bed patient, 1 emergency department patient, and 4 rehabilitation) patients that were currently being served by the facility. Findings include:

See specific tags:

C-0278 Failure to maintain a clean and sanitary environment

Based on observation, interview, and document review, the facility failed to maintain a clean and sanitary environment resulting in the potential for spread of infectious agents to the 3 in-patients, 2 observation patients, 1 swing bed patient, 1 emergency department patient, and 4 rehabilitation patients that were currently being served by the facility. Findings include:

During facility tour on 4/15/2019 at 1100, G-020, a storage room, was found to have heavy dust on top of 2 of 2 refrigerator/freezer units present. This finding was confirmed by Staff C at the time of discovery. Directly across the hall from this room was a small area in which 2 cardboard boxes were observed to be sitting on the floor. Staff C was queried on 4/15/2019 at 1101 as to if the boxes should be sitting on the floor to which he stated "no" and immediately picked them up and placed them on the cart that was sitting next to them in the same area.

On 4/15/2019 at 1103, the pharmacy was entered and found to have a chair with a vinyl seat sitting in the corner in the ante-area outside of a room containing the ventilation hood. The front corner of the chair seat was observed to have a small piece of vinyl missing and the fabric mesh underneath was exposed. Additionally, upper and lower medication drawers and cupboards in the main pharmacy area were found to have tape residual and residue present. Some of the tape covering labels on the drawers and cupboards had edges that were curling and darkened. These findings were confirmed by Staff B at the time of discovery.

The dining area of the cafeteria was entered on 4/15/2019 at 1118. Crumbs were found to be present on top of the toaster and on the tray underneath and around the toaster. The inside walls and door of the microwave were found to have food residue present which was dry and crusted in appearance. A display case on the far wall was found to have heavy dust on top of it and three pictures hanging on the wall were also found to have heavy dust present along the top edge. In an area sectioned off for private dining, the window sills were found to have heavy dust present. These findings were confirmed by Staff B at the time of discovery.

On 4/15/2019 at 1124, nine cardboard boxes were found stacked and sitting on the floor outside the G-013 housekeeping closet.

On 4/15/2019 at 1132, an oxygen storage area was entered and found to have a paper sign on the wall secured by duct tape which was curled and blackened at the edges.

On 4/15/2019 at 1200, the Lab was entered and found to have heavy ice build-up in the freezer portion of the refrigerator in the area where patient labs were drawn. In the large 3-door refrigerator, there were opaque droplets that had been splashed across the back wall and were streaking downward. Additionally, there was small debris in the floor of the refrigerator. In the large 1-door refrigerator, there was a splashed opaque substance on the door and floor of the unit. These findings were confirmed by Staff B at the time of discovery.

On 4/15/2019 at 1403, the emergency department (ED) soiled utility room was entered and a metal trash can with mechanical metal lid was observed to have moderate to heavy rust present. Additionally, 4 patient belongings bags, 3 labeled with Patient #21's name and 1 labeled with Patient #22's name, were found sitting on a counter amongst other used equipment. Staff C was queried on 4/15/2019 at 1405 as to if this is where patient belongings should be kept to which he replied, "(Patient #21) is suicidal. This is not where they should be...Normally the belongings would be kept with the patient or given to the family, but in this case, there was no family to give them to."

ED Room #4 was entered on 4/15/2019 at 1420. Five small brown colored spots were observed on the wall above the head of the bed. Staff C was queried as to what the brown colored spots were to which he stated, "It's either iodine or blood."

During the initial tour of the ED on 4/15/2019 at 1423, ED Room #1 was entered and found to have a sharp's box present with an expiration date of 4/15/2019. This was confirmed by Staff B at the time of discovery. Room #1 was entered again on 4/16/2019 at 0948 and the same sharps box was found to be present. This was confirmed by Staff C at the time of discovery. Staff C was queried on 4/16/2019 as to who was responsible to change the sharps boxes when they were full or had expired to which he stated it was the nurse's responsibility.

The power injector arm of the CT (computerized tomography) machine was observed to be dusty. The adhesive on a label on the arm was halfway off and free to move as air currents or mechanical movements caused it to. Additionally, there was a white sticky substance on it. These findings were confirmed by Staff P at the time of discovery.

Room 228, identified by Staff Q as being a patient-ready room, was entered on 4/15/2019 at 1449. Five to six brown spots were observed on the ceiling next to the shower and above the toilet. Additionally, there appeared to be brown spots in the indentations of the ceiling. The slanted top of the clothes closet was found to have heavy dust and there was a dried light brown liquid stain on the the window sill. These findings were confirmed by Staff B at the time of discovery.

Room 227, also a patient-ready room, was entered on 4/15/2019 at 1452. The wall next to the sink had streaks of dried clear fluid running down the wall. Two strips of corkboard were present at the head and the foot of the bed for both Beds 1 and 2. These findings were confirmed by Staff B at the time of discovery.

Room 2-023 was entered on 4/15/2019 at 1503 and found to have a large yellow cabinet for oxygen tank storage. On the outside of the cabinet was a copious amount of tape residue and residual.

Facility job description titled "Housekeeper" last updated 2/2014 states: "Perform any combination of light cleaning duties to maintain...a clean and orderly manner...Essential Duties and Responsibilities...Dust and polish furniture and fittings, clean metal fixtures and fittings..."

Facility job description titled "Janitor" last updated 2/2014 states: "Keep buildings in clean and orderly condition...Collect and dispose of trash following approved procedures and infection control plans, dust and damp mop floors following procedures as assigned, move equipment and furniture for proper cleaning and place furniture back in correct placement, clean all assigned areas with the use of assigned materials and equipment. Sanitize all surfaces. Follow the eight step cleaning procedure. Wash walls, windows, furniture, baseboards and other items needed to maintain a clean safe environment for our patients, visitors and staff. Seek out areas that require cleaning and take initiative to complete the task..."

Facility policy titled "Environmental Cleaning and Linen Management" last revised 1/7/2019 references "Attachment A-Environmental Cleaning Tasks and Schedules By Area." This attachment did not come with the policy and was requested separately. The attachment does not have any dates present for origination or for revision. Attachment A contains a table indicating the cleaning task and how often it should be cleaned. It states, "Wall washing-annual or as requested or as needed...Microwave cleaning-daily or as used by user...Overhead ledges-daily...Light fixtures and vents-daily...Horizontal surfaces-daily..."



30988

On 04/15/2019 at 1115 the dinning room was entered. Immediately in front of the door was a chest freezer the contained ice cream with a build up of ice on the inner walls of the freezer , the door to the freezer was held together with 3 pieces of duct tape in 3 corners of the door. The handle was covered with black dirt/grime finger prints. The floor around the bottom of the freezer had a 4-5 inch black crusted dirt area around the bottom. The finding was confirmed with staff C at the time of discovery.

On 04/15/2019 at 1140 room G-042 was entered. The Laundry room wash tub was covered with heavy dirt. The window next to the wash tub was covered with heavy dirt and lint. The finding was confirmed with staff C at the time of discovery.

On 04/15/2019 at 0200 room 016 in the Emergency Department (ED) was entered. The cupboards around the sink area had multiple splashes of a dried tan substance over the surface. This room was a patient ready room. The finding was confirmed with staff C at the time of discovery.

On 04/15/2019 at 0230 the CT scan room was entered. The power injector arm had splashes of a sticky orange substance over the upper surface of the arm. This room was patient ready. The finding was confirmed with staff C at the time of discovery.

Based on observation, interview and document review the facility failed to meet the swing bed requirements for 4 of 4 swing bed patients medical records reviewed (#7, 18, 19, 20), resulting in the potential for less than optimal outcomes. Findings include:

C-0385 The facility failed to provide an ongoing program of activities
C-0386 The facility failed to provide medically-related social services to attain/maintain the well being of each patient
C-0404 The facility failed to ensure that a dentist was available for the residents

Based on observation, interview and document review the facility failed to provide an ongoing activity program to meet the physical, mental and psychosocial well-being needs of each resident, for 4 of 4 (#7,18,19, and 20) swing bed patients. This has the potential to result in less than optimal treatment outcomes for swing bed patients served by the facility. Findings include:

On 4/16/2019 at 0855 patient #7 the only current swing bed patient was interviewed, she stated "I just get up and watch TV, there isn't much else to do." It was observed that there were no planned activities posted for her in the room or at the nursing station.

On 4/17/2019 at 1030 during medical record review for 4 swing bed patients ( #7, 18,19, and 20) it was revealed that there were no assessments related to recreational needs and no planned activities posted for any of the patients in their medical record.

On 4/17/2019 at 1130 staff I, the director of accreditation of stated, "We do not have planned activities for the skilled care patients."

On 4/17/2019 at 1200 the policy titled, "Swing Bed Activities Program" #4494345 dated approved 02/2018, was reviewed. On page 1 of 2 under policy it states "Participants in the swing bed program have individualized physical, mental, psychosocial, creative and recreational needs...The program will be designed to meet the appropriate needs of the individual patient..".Under Procedure it states "The rehabilitation Department and Social work Department staff will: 1. Meet with the swing bed patient...as soon after the admission to the swing bed program for review of social activities and lifestyles...Information obtained will be documented in patients chart...Invite and encourage patient to participate...Music, Newspapers, large print readers digest, checkers, card games, board games, craft projects, books, videos, puzzles, crossword puzzles, letter writing...List pertinent information...in the patient record."

Based on interview and document review the facility failed to provide for the medically-related social services needs of each resident, for 4 of 4 (#7,18,19, and 20) swing bed patients. This has the potential to result in less than optimal treatment outcomes for swing bed patients served by the facility. Findings include:

On 4/17/2019 at 1030 during medical record review for 4 swing bed patients ( #7, 18,19, and 20) it was revealed that there were no assessments documented by the social worker related to the admission to the swing bed program.

On 4/17/2019 at 1130 staff I, the director of accreditation of stated, "We do not have anyone coordinating the swing bed program to ensure that all of the documentation is completed."

On 04/17/2019 at 1300 staff II the social worker who was interviewed by telephone, was asked if there was a social work assessment completed when the patients were discharged from in patient and then admitted to swing bed status. He stated "No, an assessment was not done when the patient was admitted to swing bed."

On 04/17/2019 at 1200 the policy titled "Swing Bed Interdisciplinary Team" #4494357 dated approved 02/2018 was reviewed. On page 1 of 2 under policy it states "The Interdisciplinary team will review each patients assessment a minimum of 48 hours from admission..."

Based on document review and interview, the facility failed to either maintain an agreement or have a Dentist on staff to provide dental services for swing bed patients resulting in the potential for poor patient outcomes for all swing bed patients. Findings include:

On 04/17/2019 at approximately 1300, review of documents provided by the facility listing services provided either directly by the facility or by agreement/arrangement, lacked information regarding Dental services.

On 04/17/2019 at 1315, during an interview with Staff H (Administrator) when queried if the facility had a Dentist on staff or if they have an agreement with a Dentist, staff A stated, "We do not."