The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.


Based on observations, interviews, review of Environment of Care Records and information obtained from the Centers for Disease Control and Prevention website, the hospital failed to maintain a clean and safe physical environment in eight patient rooms observed during a tour on 4/27/15 as evidenced by dust, trash, dark colored areas on floors and in showers and a leaky toilet. This affected patient rooms 652, 660, 670, Room 3 Palliative Care, 572, 571, 357 and 281 and has the potential to affect all patients admitted to the hospital.

Findings include:

During a tour of patient rooms beginning at 1400 on 4/27/15 the following conditions were observed:

1. Patient Room 652/ Unoccupied (Described as "clean" by staff):
Bathroom: Gray colored dust/dirt on floor in lower right corner - seen and confirmed when surface wiped with tissue by surveyor. Small piece of tissue on floor.

Flooring under sink (located in room where bed is positioned, sink not located in bathroom) had multiple dark brownish-black colored areas.

2. Patient Room 660:
Dark black colored area in upper right corner of floor in shower.

3. Patient Room 670: (Occupied by patient)
Bathroom: Standing water on floor on right side of toilet - a piece of toilet paper on the floor was soaked with a clear colored fluid. The Environmental Service (EVS) Director, Employee Identifier (EI) # 1, touched the floor and said, "There's water down here." Dark reddish-brown areas on floor behind toilet where floor and wall meet.

4. Patient Room 3 - Palliative Care: Window blinds dusty. Two pieces of white colored tissue on floor (reported as clean - unoccupied).

5. Patient Room 572: Dark black colored areas in corners of shower. (unoccupied).

6. Patient Room 571: Dark black colored area behind toilet on floor (where floor and wall meet).

7. Patient Room 357: Grayish - black areas around edges of floor (where floor and wall meet). Occupied by patient.

8. Patient Room 281: Dark grayish black areas on tile floor in bathroom.

EOC (Environment of Care) Rounds:

A review of the EOC Rounds dated 4/6/15 revealed the following concerns were identified by the hospital on [DATE]:

1). Infection Control: Expired milk in "fridge" (refrigerator).

2). General Safety/Security: Flooring has "divets."


During an interview on 4/28/15 at 11:09 the Chief Quality Officer / Employee Identifier (EI) # 2 stated EOC Rounds are usually conducted in empty patient rooms, not in patient care areas.

During an interview on 4/28/15 at 10:52, the Director of Plant Operations / EI # 3, said a tour of the environment is done every Tuesday by Plant Operations and the EVS Director. However, the room selection is "random. Do not go in rooms with patients in them." EI # 3 was asked if he had any knowledge about the toilet leaking in room 670 and he said, "No. " EI # 3 said he was notified about the leak by the EVS Director on 4/27/15 (first day of the survey). The Director was asked if the leak was repaired and he said no. "Yesterday you (State Surveyor) were in the room with staff and last night Plant Operations had an emergency." EI # 3 was asked if an assessment had been made about the leak. EI # 3 stated the assessment was, "Not written," but the patient occupying room 670 is to be moved today and repair will begin when the room is "open." EI # 3 said rounds are also made on an individual basis of "unoccupied" rooms.

Information obtained from Centers for Disease Control and Prevention Website:

As part of routine building maintenance, buildings should be inspected for evidence of water damage and visible mold. Conditions causing mold (water leaks,etc.) should be corrected to prevent mold from growing. Excess moisture is generally the cause of indoor mold growth.

Dampness results from water incursion and becomes a problem when various materials in buildings become wet for extended periods. Dampness provides moisture that supports the growth of bacteria, fungi (i.e., mold)... Exposure to damp and moldy environments may cause a variety of health effects such as nasal stuffiness, throat irritation, coughing, wheezing, eye and/or skin irritation, or none at all.

The lack of clean, leak free rooms and bathrooms used by patients represents a failure by the hospital to maintain the patient rooms/toilets to ensure patient safety and comfort. The Environment of Care rounds fail to include inspection of patient care areas including rooms/bathrooms occupied by patients.