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.

IZARD COUNTY MEDICAL CENTER, LLC 61 GRASSE STREET CALICO ROCK, AR 72519 Dec. 7, 2018
VIOLATION: PATIENT ACTIVITIES (483.15(F)) Tag No: C0385
Based on review of policies and procedures, record review, and interview, it was determined the facility did not employ a qualified professional to direct the Swing Bed Activities program. Failure to employ a qualified professional did not ensure the Swing Bed patients were receiving activities designed to meet the interests, physical, mental and psychosocial well-being of each patient. The failed practice affected all Swing Bed patients on 12/07/18. Findings follow:

A. Review of Policy #11 on 12/04/18 titled "Activities Services" showed A Social Worker/Activities Director would assess each patient's interest in activities upon admission and as needed.

B. Review of Activities Assessment of Swing Bed Patients #1 and #2 showed the assessments were not performed by a credentialed activity director.

C. The above findings in A and B were verified by the Director of Nursing on 12/07/18 at 8:30 AM
VIOLATION: SPECIALIZED REHABILITATIVE SERVICES Tag No: C1622
Based on review of Physical Therapists' (PT) Job Description, review of Physical Therapists' personnel files and interview, it was determined one (PT #1) of two (PT #1 & #2) therapists did not have evidence of current CPR (Cardio-Pulmonary Resuscitation) certification, per Physical Therapists' Job Description. By not having evidence of these qualifications, the facility could not assure services provided to patients would be given by a qualified therapist. The failed practice had the likelihood to affect all patients that receive Rehabilitation Services. Findings follow:

A. Review of the Physical Therapists' Job Description showed the therapists should have CPR certification.

B. Review of Physical Therapists' personnel files showed Physical Therapist #1's CPR certification expired 08/2018.

C. During an interview on 12/04/18 at 10:55 AM, the Director of Physical Therapy verified the findings at B.
VIOLATION: PHYSICAL PLANT AND ENVIRONMENT Tag No: C0910
Based on observation, document review and interview, it was determined the facility failed to meet the Condition of Participation for Physical Plant and Environment and there was an Immediate Jeopardy to patient, visitors and staff safety in that the faciltiy failed to:
1) Maintain the facility structure and physical environment that was safe for patients, visitors and staff in that the roof structure was unstable in areas; (See C-0221)
2) Prevent active water leaks in the ceiling as observed in a storage room; (See C-0221)
3) Maintain ceiling tiles that were intact and free of water damage and mold in multiple areas of the facility: Patient Rooms #11, #14, #15 and #16; kitchen; staff and patient restrooms; nourishment room; Family Dining Room; Dish Room; Nurses Station; medication room; clean storage; CT; x-ray; Physical Therapy; wound care; hallways; Information Technology office; Business Office; Medical Records; Transcription Room; Nursing Storage closet; soiled utility room and electrical closet. The failed practice affected the census of six patients on 12/04/18, all staff and visitors. (See C-0221)

The cumulative effect of these failed practice resulted in an Immediate Jeopardy to patients, visitors and staff in that the safety and integrity of the roof could not be assured.

The Immediate Jeopardy was abated with the following plan on 12/04/18 at 5:20 PM.
1) Room #11, #14, #15 and #16 were inspected and are empty at this time. Nursing staff has been informed not to place new patient admissions in those rooms until issues are corrected and documented correction in place. At this time, Room# 20, #21,# 23, #24 and #25 are occupied. Room #19 and #22 are available for patient admissions. Wednesday 12/05/18 is outpatient surgery day. If a patient has to stay overnight for monitoring, they will be held in the recovery room area where three beds are available.

2) Ceiling tiles in the following areas with stains, that are not intact or in contact with light fixtures, vents or fans will be replaced on 12/05/18 (patient rooms and med rooms completed on 12/04/18 and monitored twice daily by maintenance with appropriate documentation. Monitoring will include checking the entire ceiling in each of these rooms. The Registered Nurse/Infection Contorol/Risk Manager will accompany maintenance for monitoring to inspect for the possibility of any infectious issues or risks involving patients and staff. Maintenance will report findings daily to the Chief Executive Officer (CEO) regarding the nurses station, dietary, medical records, transcription, wound care room, ultrasound room, stress lab, bathroom off of hallway and the hallway, storage area, nursing storage, family dining room, medicine room at nurses station, CT room and x-ray room, lab, hallway outside of recovery room, and old storage room.

3) Staff present 12/04/18 were educated on what to monitor, how to check and look for new leaks and the process of reporting their findings, If a leak occurs in a patient area and a patient is present, the nursing staff will move the patient to another room. Maintenance is on call 24/7 and staff were instructed to call them immediately upon the discovery of a leak. Maintenance will report to the facility and inspect. Education will continue today at the change of shift and signatures obtained. Education will continue daily until all staff are aware and informed of the necessary measures.

4) These measures will be added and monitored by the Quality Assurance Committee and team.

5) Americore Health CEO was informed of the Immediate Jeopardy and stated he will send someone immediately to look at the roof and get quotes for replacement or repair.
VIOLATION: CONSTRUCTION Tag No: C0912
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, policy review and interview, it was determined the facility failed to follow their policy to maintain the facility structure and physical environment that was safe for patients, visitors and staff. A safe environment was not maintained in that the roof structure was unstable in areas; there was an active leak in the ceiling in a storage room; discolored ceiling tiles showed evidence of previous moisture in multiple areas: Patient Rooms #11, #14, #15 and #16; kitchen; staff and patient restrooms; nourishment room; Family Dining Room; Dish Room; Nurses Station; medication room; clean storage; CT; x-ray; Physical Therapy; wound care; hallways; Information Technology office; Business Office; Medical Records; Transcription Room; Nursing Storage closet; soiled utility room and electrical closet. The failed practice affected the census of six patients on 12/04/18, all staff and visitors. Findings included:

A. Record review of the facility's policy titled, "Hazard Surveillance Survey (Environmental Rounds/Internal Audits)", dated 02/2017 showed Hazard Surveillance surveys were to be conducted every six months in patient care areas and annually in non-patient care areas. The policy stated:
1) A copy of the completed Hazard Surveillance Rounds Internal Audit was to be delivered to the area Director and the Director was responsible to ensure correction of any identified deficiencies.
2) Documentation of completion of deficiencies will be returned to the Safety officer within 10 working days of the survey.
3) The policy stated the Safety Officer would compile a summary of the reports and present them at the quarterly Physical Environment Committee.
4) The Physical Environment Committee will review the report and identify any unresolved issues, trends, or recurring problems and develop actions to be taken if needed.
5) The Committee will also review previous actions taken to assess the effectiveness of the process and improvements made.

B. On 12/05/18 at 9:00 AM, review of the facility's "Maintenance Policy and Procedure Manual," review date of 01/09/18, showed plant operations and maintenance would provide a safe, clean, structurally sound environment and this shall be achieved in the hospital through development and implementation of the Plant Operation and Maintenance Program.

C. Review of the policy and procedure titled "Environmental Criteria," received on 12/04/18, showed ceiling tiles were to be replaced as soon as repair work is completed. In patient care areas, a temporary cover was to be placed (plastic sheeting) over the opening to avoid mold/fungi falling into the environment, that ceiling tiles should be replaced when wet, stained or damaged.

D. During an interview on 12/03/18 at 3:08 PM, the Director of Maintenance stated that areas of the ceiling that were discolored or stained indicated a water leak from the roof or sometimes condensation.

E. Observation of the facility on 12/03/18 with the Director of Maintenance showed the following:

1) 12:29 PM: Information Technology (IT) office: There was a total of eleven discolored ceiling tiles.

2) 12:34 PM: Business Office: one large ceiling tile had a dark stain covering the tile completely. A hole was observed in the ceiling tile and the Director of Maintenance stated there had been a leak in one spot. A small room off of the main business office area had one ceiling tile with a brown spot and an area of approximately 2 feet x 3 feet that was missing ceiling tile. 12:37 PM: The ceiling tile area next to a light and over an electrical outlet had three brown spots.

3) 12:41 PM: Medical Records: Patient Medical Records are stored on 12 open shelves. There were medical records stored in file folders. The medical records are not protected from water damage. The ceiling tile had ten different spots of brown discoloration. The top rack to the left of the door had a basin that the Director of Medical records stated was used to catch the water leaks, but that there had not been leaks in that area in quite some time. The bin did not contain water at the time of observation, but the ceiling tile above it was discolored in spots. There were paper medical records stored next to the bin. The carpet at the entrance to the medical record storage room was discolored a brown color. The Director of Maintenance stated at the time of observation that the area had been flooded at one time.

4) 12:49 PM: Transcription Room: Three ceiling tiles observed with brown spots.

5) 12:51 PM: Wound Care area that is labeled "Ultrasound 2": Three discolored ceiling tiles with evidence of water damage. An accumulation of dust observed on the air return vents located in the room.

6) 12:52 PM: Ultrasound room and stress lab: Four discolored tiles and cracks and breaks in the integrity of the ceiling tile.

7) 12:59 PM: Bathroom (located outside the Ultrasound room) had a 2' x 2' area missing ceiling tile; five ceiling tiles were discolored. In the missing ceiling tile area, a one gallon black metal can was observed suspended in the area of missing ceiling tile and hanging above the ceiling. Upon removal and inspection by the Director of Maintenance, the paint can was observed approximately one-fourth of the way full of liquid identified by the Director of Maintenance as "water." The Director of Maintenance was interviewed and asked if the bathroom was used by patients to which he stated they didn't use it much but could if they were outpatients.

8) 1:05PM: Old Storage Room: Observation showed a leaking drip from the ceiling that had puddled on the floor and wet four of the nine tables that were stored on their side adjacent to the area where there was a drip There were two buckets in the ceiling: one toward the center of the room and one in the corner to the right of the door resting on a piece of wood diagonally. A one inch gap from the floor to where the wall started in the corner and to the right of the door into the storage room. There were three single, ceramic type light receptacles in the ceiling, two of the three were not working. The ceiling tiles around the non-working overhead lights were stained brown. There was a total of eight missing ceiling tiles and two additional tiles that were broken and exposed.

a) Open shelves along the three of four walls in the room contained patient clinical records. The Director of Medical Records confirmed on 12/03/18 at 1:10 PM that the clinical records stored in the area were old and could be discarded. The clinical records on the top shelves showed evidence of previous water damage (black areas, discolored page edges and stained paper folder).

b) There were 17 cardboard boxes stacked one on top of the other with three boxes resting directly on the floor. The cardboard boxes showed evidence of water damage on the tops and sides to varying degrees. The Director of Medical Records confirmed at 1:21 PM that the boxes contained old medical records and that the boxes were discolored and stained.

c) There were multiple pieces of equipment stored in the room. The Director of Maintenance confirmed multiple items were stored in the room, such as housekeeping floor buffer, floor cleaner, Hydrocollator tank, suction equipment, etc ...The housekeeping floor buffer and cleaner were the only two actively in use.

d) An enclosed wall-mounted cabinet located to the left of the room door showed multiple wires that were not connected and the ends were not secured with wire connectors or wire terminals. The Director of Maintenance stated the wires were inactive at the time of observation.

9) 1:27 PM: Physical Therapy: Two ceiling tiles with brown discoloration.

10) 1:32 PM: Nursing Storage closet: (across from Administrator's office) a 2' x 2' area tile observed laying on the floor. The tile was stained and discolored. Two Datascopes (for checking vital signs) were stored in the room, one # was tagged as services due 12/2017 and one # was tagged as due for service 12/2017. The Director of Nursing was interviewed on 12/03/18 at 1:37 PM and stated the Datascopes were not functional because there were missing parts and that is why they were not serviced.

11) 1:39 PM: Soiled Utility room: One ceiling tile that is dark and discolored; a total of twelve floor tiles missing from the baseboard area. This was verified by the Director of Maintenance at 1:39 PM on 12/03/18.

12) 1:43 PM: Nourishment Room: ceiling vent with an accumulation of dust.

13) 1:43 PM: Dish Room: One area of discoloration and a hole in the ceiling tile. The Director of Maintenance stated on 12/03/18 at 1:43 PM he had previously had a leak in the area.

14) 1:49 PM: Family Dining Room: an accumulation of dust on the air vent. One ceiling tile above the vent with a dark discoloration. On the inside of a closet, the air duct on the ceiling tile and around the vent were discolored. The Director of Maintenance confirmed 12/03/18 at 1:49 PM that there had been a leak in the area.

15) 1:53 PM: Kitchen: Cook #1 and Cook #2 were interviewed on 12/03/18 at 1:53 PM and stated there were areas in the kitchen that had leaked previously. The areas identified had dark discolorations on the ceiling tile: between the plate warmer and ice machine, beside the ventilation hood and near the microwave.

16) 1:58 PM: Staff Restroom: Vent with an overall accumulation of dust. Three ceiling tiles discolored. The Director of Maintenance confirmed on 12/03/18 at 1:58 PM there had been a leak in the area previously.

17) 2:05 PM: Electrical Storage: One area of ceiling tile discoloration observed.

18) 2:12 PM: Room #11: Observation showed two ceiling tiles with dark and discolored areas on the tile.

19) 2:13 PM: Room #12: Room heating and cooling filters observed with a thick accumulation of dust.

20) 2:17 PM: Room #14: Observation of the ceiling tile showed there were seven spots of dark discoloration on the ceiling tile. This room was a semi-private room occupied by one patient at the time of observation.

21) 2:19 PM: Room #15: (identified by the Director of Maintenance as the old critical care room) Observation showed six ceiling tiles with dark discoloration.

22) 2:20 PM: Room #16: six ceiling tiles that were dark and discolored, three had been painted but the stain was still visible.

23) 2:22 PM: Nurses Station: Three ceiling tiles with dark discolored area, bugs observed in two of two fluorescent light fixtures. Four areas of the floor, greater than 12 inches each that the laminate is worn down to the wooden composite core. By interview at the time of observation the Director of Maintenance stated a roof drain had become plugged and resulted in a flood at the nursing station. This occurred within the last one year. The floor buckled and that caused the laminate to wear off. This was also confirmed by the Unit Secretary #1. The confirmation occurred at the time of observation.

24) 2:32 PM: Medication Room: Observation with LPN (Licensed Practical Nurse) #2 and Director of Maintenance. Two ceiling tiles with discoloration; one of two discolored ceiling tiles had large areas of black discoloration and a large hole in the tile in the black area. The Director of Maintenance confirmed the discolored tile appeared to be "mold."

25) 2:50 PM: Computerized Tomography (CT) Room: Five ceiling tiles observed with discoloration. One two foot by four foot tile noted with a black area of discoloration visible. The Director of Maintenance confirmed the black discolored tile could be mold. One of the stained areas of ceiling tile was observed directly adjacent to the CT table.

26) 2:55 PM: Old X-ray room: (identified by Radiology Technician #2 as not currently in use) Five ceiling tiles with dark brown discoloration.

27) 2:56 PM: X-ray room: Discolored ceiling tile observed above the lead apron hanging area. Patient bathroom area ceiling tile discolored in the area of the air vent and one ceiling tile missing.

28) 3:04 PM: Hallway: (outside rooms 21 and 22) one ceiling tile observed with a hole and stained.

29) 3:08 PM: Laboratory: Four ceiling tiles were discolored. The Director of Maintenance stated that areas of the ceiling that were discolored or stained usually indicated a water leak from the roof or sometimes condensation.

30) 3:09 PM: Hallway (outside surgery waiting room): Five ceiling tiles had areas of dark discoloration.

31) 3:15 PM: The outside roof surface was flat and showed multiple areas of standing water. Several surfaces of the roof were identified by the Director of Maintenance as unstable and Surveyors were instructed not to walk on those areas of the roof. At the time of observation, the Director of Maintenance was asked how long the roof had been leaking and stated about 10 years and the facility was trying to get 30 years out of a 15 year roof.

F. The findings in E. 1 - 31 were verified at the time of observation by the Director of Maintenance.

G. 12/04/18 at 8:40 AM: Review of the facility Committee of the Whole meeting minutes from 06/2017 - 09/2018 showed no documentation of the reported leaks or condition of the roof of the facility. On 12/04/18 at 10:00 AM the Maintenance Weekly Inspections Life Safety report was reviewed for 11/2017 - 01/2018 and there was no documentation of reported leaks or condition of the roof.

H. 12/07/18 at 10:30 AM the Director of Maintenance provided documentation of environmental rounding dated 10/11/17 and stated there was no other documentation of environmental rounding. A document titled "Physical Environment Committee" was also provided that was dated 10/11/17. The document stated there was no previous minutes and that this was the first meeting for the Physical Environment Committee. An item titled "General Safety" included the statement that trends for environmental clinical and non-clinical areas included stained ceiling tiles and the Director of Maintenance was to follow-up on repairs.

I. On 12/04/18 at 10:00 AM, the Chief Executive Officer (CEO) was interviewed and a request was made for any documentation of actions taken or leadership and owners were informed of the condition of the roof. The CEO stated the owners of the facility were aware the roof was leaking and this was reported with the buyout in July of 2017. Documentation provided on 12/04/18 at 10:32 AM for 11/02/17 and 02/13/18 showed Facilities Management requested a new roof and included a statement that the oldest part of the roof was more than [AGE] years old and the square footage needed was 28,000 square feet. Estimate for removal and replacement was $15 - $20 per square foot ($460,000.00 to $560,000.00). A quote for restoration of approximately 8000 square feet of two roofs and a wall (or one-third of the roof) was provided dated 09/24/18 with the total needed as $48,000.00. Documentation on 10/31/18 showed documents were requested for a loan to repair/replace the hospital's roof. As of the survey conducted 12/03/18 - 12/07/18, there was no documentation provided that included specific plan or time line for the roof to be repaired or replaced.







Based on policy and procedure review, observation and interview, it was determined the facility failed to ensure the physical plant was maintained to assure the safety of the patients and cleanliness of the supplies necessary to provide care to the patients in that equipment was not functional; the Clean Linen Room, one of one exterior supply room and patient care rooms were not physically maintained in two (109-2 and 12) of 13 (Room 109, Rooms 11-12, 14, 15, 17, 19-25) patient care rooms in that there were holes in the ceiling, the wall and ceiling tiles were discolored with water and mold stains. Failure to ensure equipment was functional and the physical plant was maintained did not ensure patients and patient care supplies were housed in a safe, clean, and functional environment. The failed practice had the potential to affect any patient assigned to Room 109-2 and 12 and whose care required the supplies housed in the exterior supply room. Findings follow:

A. Review of the policy and procedure titled "Environmental Criteria," received on 12/04/18, showed ceiling tiles were to be replaced as soon as repair work is completed. In patient care areas, a temporary cover was to be placed (plastic sheeting) over the opening to avoid mold/fungi falling into the environment, that ceiling tiles should be replaced when wet, stained or damaged.

B. Observation in Room 109-2 at 1:25 PM on 12/03/18 showed the 2 bed (closest to the window) nursing call light did not alert in the room, or at the nursing desk when pressed. Observation also showed a stockinette stuffed into the wall space between the heater/air conditioning (AC) unit and the wall; and on the left side of the heater/AC unit 5 inches of sheetrock was torn away from the wall. During an interview with the Director of Nursing (DON) at 1:30 PM on 12/03/18 the above findings were verified.

C. Observation in Room 12 at 1:45 PM on 12/03/18 showed sheetrock torn away from the wall on both sides of the heater/AC unit. During an interview with the DON at 1:50 PM on 12/03/18 the above findings were verified.

D. Observation in the Clean Supply Room at 2:05 PM on 12/03/18 showed a ceiling tile support broken and hanging down from the ceiling 4 inches. During an interview with the DON at 2:10 PM on 12/03/18 the above findings were verified.

E. Observation in the exterior Supply Room at 1:35 PM on 12/06/18 showed the following:
1) Immediately over the entry way into the Supply Room were three pieces of cardboard were observed in the metal frame intersection that supported three different ceiling tiles. The Central Sterile Technician stated during an interview at 1:35 PM on 12/06/18 the pieces of cardboard were there for two months now to cover up holes in the three ceiling tiles.
2) Observations above the first row of supply shelving, located on the exterior wall adjacent to the door, showed four of seven ceiling tiles were bulging downward and discolored with multiple sizes and variations of color ranging from light brown to black. Examples of medical supplies stored underneath the stained and bulging ceiling tiles included one case of graduate pitchers, two cases of Y Blood sets, one case of Buretrol Add-on Sets, two boxes of Clearlink Conti-flo Solution Sets, three boxes of Medline 25 gauge Safety Needles.
3) Observations on the end wall between the first and second rows of shelving included a six inch hole in the concrete block wall that was stuffed with blue paper and then painted over. Observation of the light fixture between the first and second rows of shelving showed a discolored tile on either side of the fixture.
4) Observations on the second row of supply shelving showed five of seven ceiling tiles discolored with multiple sizes and variations of color ranging from light brown to dark brown. Observations at the end of the second row, showed a 12 inch by 12 inch opening in the wall that bordered the ceiling. Examples of medical supplies stored underneath the stained and bulging ceiling tiles included one case of elastic bandages, one box of Snugfit fitted stretcher sheets, one case of laceration trays, one case of pediatric ambu bags, two cases of adult ambu bags, one box containing ten anesthesia circuits and one box containing twenty anesthesia circuits, respiratory therapy supplies that included one box of CO2 (carbon dioxide) nasal samplers, one case of Bitrac ED mask and one box of Incentive Spirometers.
5) Observations on the back wall of the Supply Room showed an AC unit mounted at the ceiling. The AC unit was covered in black grime, spider webs, and dust.
6) Observations in the far right corner of the room showed a heating unit suspended from the ceiling. Observation of the ceiling tiles immediately in front of the heater showed multiple sizes and variations of color ranging from light brown to dark brown stains.
7) Observations showed a black electrical cable strung from the far right corner of the room, above the second row of shelving to an electrical box mounted on the wall immediately to the right of the door as one entered the Supply Room. The electrical cable was attached to the metal framework of the ceiling tiles by zip ties at one spot over the second row of shelving.

F. During an interview with the Central Sterile Supply Technician from 1:30 PM to 2:30 PM on 12/06/18 the findings in B, C, D, and E were verified.
VIOLATION: PREMISES ARE CLEAN AND ORDERLY Tag No: C0924
Based on observation, policy review and interview, it was determined the facility failed to follow their policy to maintain a clean and orderly physical environment that was safe for patients, visitors and staff. A clean and orderly environment was not maintained in that the roof structure was unstable in areas; there was an active leak in the ceiling in a storage room; discolored ceiling tiles showed evidence of previous moisture in multiple areas (patient room #11, #14, #15 and #16; kitchen; staff and patient restrooms; nourishment room; family dining room; dish room; nurses station; medication room; clean storage; CT; x-ray; Physical Therapy; wound care; hallways; Information Technology office; Business Office; Medical Records; Transcription Room; Nursing Storage closet; soiled utility room and electrical closet); Dust accumulated on air vents (wound care room, ultrasound room, nourishment room, Family Dining Room, staff restroom, patient room #12, clean storage and the medication room); non-intact laminate flooring at the nursing station; bugs in flourscent light fixtures at the nursing station, and exit door on nursing unit with broken latch. The failed practice affected the census of six patients on 12/04/18, all staff and visitors. Findings included:

A. The following was verified on 12/03/18 at the time of observation by the Director of Maintenance:
1) 12/03/18 at 12:29 PM: Information Technology office: A total of eleven discolored tiles were observed. The Director of Maintenance was asked if there were leaks in the roof and stated there are and that "they're trying to get 30 years out of a 15 year roof."

2) 12/03/18 at 12:34 PM: Business Office: one large ceiling tile was observed with a dark stain covering the tile completely. A hole was observed in the ceiling tile and the Director of Maintenance stated there had been a leak in one spot. A small room off of the main business office area had one ceiling tile with a brown spot and an area of approximately two feet by three feet that was missing ceiling tile.

3) 12/03/18 at 12:37 PM: The ceiling tile area next to a light and over an electrical outlet had three brown spots.

4) 12/03/18 at 12:41 PM: Medical Records: Patient Medical Records were stored on 12 open shelves. The medical records were paper and stored in file folders. The medical records were not protected from water damage. The ceiling tile had ten different spots of brown discoloration. The top rack to the left of the door had basin that the Director of Medical Records stated was used to catch the water leak. The bin did not contain water at the time of observation, but the ceiling tile above it was discolored. There were paper medical records stored next to the bin. The carpet at the entrance to the medical record storage room was discolored a brown color. The Director of Maintenance stated at the time of observation that the area had been flooded at one time.

5) 12/03/18 at 12:49 PM: Transcription Room: Three ceiling tiles observed with brown spots.

6) 12/03/18 at 12:51 PM: Wound Care area: Three discolored ceiling tiles with evidence of water damage. An accumulation of dust observed on the air return vents located in the room.

7) 12/03/18 at 12:52 PM: Ultrasound room and stress lab: Four discolored tiles and cracks and breaks in the integrity of the ceiling tile. Air vent has an accumulation of dust on the surface.

8) 12/03/18 at 12:59 PM: Bathroom (located outside the Ultrasound room): A two by two foot area missing ceiling tile; five ceiling tiles were discolored. In the missing ceiling tile area, a one gallon black metal can was observed suspended in the area of missing ceiling tile and hanging above the sub-ceiling tiles. Upon removal and inspection by the Director of Maintenance, the black metal can was observed approximately one-fourth of the way full of liquid, identified by the Director of Maintenance as "water" from a leak. The Director of Maintenance was interviewed and asked if the bathroom was used by patients to which he stated they didn't use it much but could if there were outpatients.

9) 12/03/18 at 1:05PM: Old Storage Room: Observation showed a leaking drip from the ceiling that had puddled on the floor and wet four of the nine tables that were stored on their side adjacent to the area where there was a drip. There were two buckets stationary in the ceiling above areas of missing ceiling tiles: one toward the center of the room and one in the corner to the right of the door resting on a piece of wood. A one inch gap from the floor surface to where the wall started in the corner and to the right of the door into the storage room. There were three single, ceramic type light receptacles in the ceiling, two of the three were not working. The ceiling tiles around the non-working overhead lights were stained brown. There was a total of eight missing ceiling tiles and two additional tiles that were broken and exposed.

a) Open shelves along the three of four walls in the room contained patient clinical records. The Director of Medical Records confirmed on 12/03/18 at 1:10 PM that the clinical records stored in the area were old and could be discarded. The clinical records on the top shelves showed evidence of previous water damage (black areas, discolored page edges and stained paper folder).

b) There were 17 cardboard boxes stacked one on top of the other with three boxes resting directly on the floor. The cardboard boxes showed evidence of water damage on the tops and sides to varying degrees. The Director of Medical Records confirmed at 1:21 PM that the boxes contained old medical records and that the boxes were discolored and stained.

c) There were multiple pieces of equipment stored in the room. The Director of Maintenance confirmed multiple items were stored in the room, such as housekeeping floor buffer, floor cleaner, Hydrocollator tank, suction equipment, etc ...The housekeeping floor buffer and cleaner were the only two actively in use.

d) An enclosed wall-mounted cabinet located to the left of the room door showed multiple wires that were not connected and the ends were not secured with wire connectors or wire terminals. The Director of Maintenance stated the wires were inactive at the time of observation.

10) 12/03/18 at 1:27 PM: Physical Therapy: Two ceiling tiles with brown discoloration.

11) 12/03/18 at 1:32 PM: Nursing Storage closet: (across from Administrator's office) a two foot by two foot area of tile was observed laying on the floor. The tile was stained and discolored. Two Datascopes (for checking vital signs) were stored in the room and available for staff use, one # was tagged as services due 12/2017 and one # was tagged as due for service 12/2017. The Director of Nursing was interviewed on 12/03/18 at 1:37 PM and stated the Datascopes were not functional because there were missing parts and that is why they were not serviced.

12) 12/03/18 at 1:39 PM: Soiled Utility room: One ceiling tile that is dark and discolored; a total of twelve floor tiles missing from the baseboard area. This was verified by the Director of Maintenance at 1:39 PM on 12/03/18.

13) 12/03/18 at 1:43 PM: Nourishment Room: ceiling vent with an accumulation of dust.

14) 12/03/18 at 1:43 PM: Dish Room: One area of discoloration and a hole in the ceiling tile. The Director of Maintenance stated on 12/03/18 at 1:43 PM he had previously had a leak in the area.

15) 12/03/18 at 1:49 PM: Family Dining Room: an accumulation of dust on the air vent. One ceiling tile above the vent with a dark discoloration. On the inside of a closet, the air duct on the ceiling tile and around the vent were discolored. The Director of Maintenance confirmed 12/03/18 at 1:49 PM that he had a leak in the area.

16) 12/03/18 at 1:53 PM: Kitchen: Cook #1 and Cook #2 were interviewed on 12/03/18 at 1:53 PM and stated there were areas in the kitchen that had leaked previously. The areas identified had dark discolorations on the ceiling tile: between the plate warmer and Ice machine, beside the ventilation hood and near the microwave.

17) 12/03/18 at 1:58 PM: Staff Restroom: Vent with an overall accumulation of dust. Three ceiling tiles discolored. The Director of Maintenance confirmed at that time there had been a leak in the area previously.

18) 12/03/18 at 2:05 PM: Electrical Storage: One area of ceiling tile discoloration observed.

19) 12/03/18 at 2:12 PM: Room #11: Observation showed two ceiling tiles with dark and discolored areas on the tile.

20) 12/03/18 at 2:13 PM: Room #12: Room heating and cooling filters observed with a thick accumulation of dust.

21) 12/03/18 at 2:17 PM: Room #14: Observation of the ceiling tile showed there were seven spots of dark discoloration on the ceiling tile. This room was a semi-private room occupied by one patient at the time of observation.

22) 12/03/18 at 2:19 PM: Room #15: (identified by the Director of Maintenance as the old critical care room) Observation showed six ceiling tiles with dark discoloration.

23) 12/03/18 at 2:20 PM: Room #16: six ceiling tiles that were dark and discolored, three had been painted but the stain was still visible.

24) 12/03/18 at 2:22 PM: Nurses Station: Three ceiling tiles with dark discolored area, bugs observed in two of two fluorescent light fixtures. Four areas of the floor, greater than 12 inches each that the laminate was worn down to the wooden composite core. By interview at the time of observation the Director of Maintenance stated a roof drain had become plugged and resulted in a flood at the nursing station. This occurred within the last year. The floor buckled and that caused the laminate to wear off. This was also confirmed by the Unit Secretary #1. The confirmation occurred at the time of observation.

25) 12/03/18 at 2:28 PM: Clean Storage: The heat/air room unit was observed with the vent soiled with an accumulation of dust. There was no cover on the vent and dead bugs were noted on the floor.

26) 12/03/18 at 2:32 PM: Medication Room: Observation with LPN (Licensed Practical Nurse) #2 and Director of Maintenance. Two ceiling tiles with discoloration; one of two discolored ceiling tiles had large areas of black discoloration and a large hole in the tile in the black area. Cobwebs and dead bugs were observed in the room. The room heat/air vent was covered with dust. The Director of Maintenance confirmed the discolored tile appeared to be "mold".

27) 12/03/18 at 2:50 PM: Computerized Tomography (CT) Room: Five ceiling tiles observed with discoloration. One two foot by four foot tile noted with a black area of discoloration visible. The Director of Maintenance confirmed the black discolored tile could be mold. One of the stained areas of ceiling tile was observed directly adjacent to the CT table.

28) 12/03/18 at 2:55 PM: Old X-ray room: (identified by Radiology Technician #2 as not currently in use) Five ceiling tiles with dark brown discoloration.

29) 12/03/18 at 2:56 PM: X-ray room: Discolored ceiling tile observed above the lead apron hanging area. Patient bathroom area ceiling tile discolored in the area of the air vent and one ceiling tile missing.

30) 12/03/18 at 3:00 PM: Exit Door (at the end of the hallway beside patient rooms #25 and #26): Observation of the exit door with the Director of Maintenance showed the door would not lock externally to prevent unauthorized access. The Director of Maintenance stated it had broken and he had not been able to get replacement part. The bottom of the door had a strip of foam, duct tape and clear tape attached to the bottom of the door. The outer edges of the door were discolored and rust was observed around the edge.

31) 12/03/18 at 3:02 PM: Room # 26: identified by the Director of Maintenance as currently not in use due to water damage from windows leaking. The Director of Maintenance stated he had caulked the windows but had not corrected the drywall and paint damage that had occurred above the heat/air unit in the room. The bathroom shower curtain rod was covered in rust.

32) 12/03/18 at 3:04 PM: Hallway: (outside room 21 and 22) one ceiling tile observed with a hole and stained.

33) 12/03/18 at 3:08 PM: Laboratory: Four ceiling tiles observed discolored. The Director of Maintenance stated that areas of the ceiling that were discolored or stained usually indicated a water leak from the roof or sometimes condensation.

34) 12:03/18 at 3:09 PM: Hallway (outside surgery waiting room): Five ceiling tiles observed with dark discoloration.

35) 12/03/18 at 3:15 PM: Observation of the roof of the facility showed multiple areas of standing water on the flat roof surface. Several surfaces of the roof were identified by the Director of Maintenance as unstable and surveyors were instructed not to walk on those areas of the roof. The Director of Maintenance was asked how long the roof had been leaking and stated "about 10 years."

B. Review of the policy titled, "Hazard Surveillance Survey (Environmental Rounds/Internal Audits)", dated 02/2017 showed Hazard Surveillance surveys were to be conducted every six months in patient care areas and annually in non-patient care areas. The policy stated:
1) A copy of the completed Hazard Surveillance Rounds Internal Audit was to be delivered to the area Director and the Director was responsible to ensure correction of any identified deficiencies.
2) Documentation of completion of deficiencies will be returned to the Safety officer within 10 working days of the survey.
3) The policy stated the Safety Officer would compile a summary of the reports and present them at the quarterly Physical Environment Committee.
4) The Physical Environment Committee will review the report and identify any unresolved issues, trends, or recurring problems and develop actions to be taken if needed.
5) The Committee will also review previous actions taken to assess the effectiveness of the process and improvements made.

C. On 12/05/18 at 9:00 AM review of the Maintenance Policy and Procedure manual, with a review date of 01/09/18 showed plant operations and maintenance would provide a safe, clean, structurally sound environment shall be achieved in the hospital through development and implementation of the Plant Operation and Maintenance Program.

D. 12/05/18 at 9:00 AM record review of the Maintenance Policy and Procedure manual, reviewed 01/09/18 showed all exit doors are to be locked after 7:00 PM. All exit doors on all floors must be kept locked 24 hours a day.

E. On 12/07/18 at The Director of Environmental services was interviewed. She stated it was the responsibility of Housekeeping to do the daily cleaning and dusting for the air return vents and heating/cooling vents. The Director of Environmental Services stated they had been short staffed and had been trying to get things caught up.
VIOLATION: ORGANIZATIONAL STRUCTURE Tag No: C0960
Based on observation, document review and interview, it was determined the Chief Executive Officer (CEO) and Governing Body failed to maintain the facility structure and physical environment that was safe for patients, visitors and staff. A safe environment was not maintained in that the roof structure was unstable in areas; there was an active leak in the ceiling in a storage room; discolored ceiling tiles showed evidence of previous moisture in multiple areas: Patient Rooms #11, #14, #15 and #16; kitchen; staff and patient restrooms; nourishment room; family dining room; dish room; nurses station; medication room; clean storage; CT; x-ray; Physical Therapy; wound care; hallways; Information Technology office; Business Office; Medical Records; Transcription Room; Nursing Storage closet; soiled utility room and electrical closet. The failed practice affected the census of six patients on 12/04/18, all staff and visitors. Findings included: (See C- 0220)
VIOLATION: PATIENT CARE POLICIES Tag No: C1016
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of Rules and Regulations for Hospitals and Related Institutions in Arkansas (2016), observation and interview, it was determined the emergency medications were not secured with a breakaway seal (per regulation) in one of one ([DIAGNOSES REDACTED]) emergency cart observed. By not maintaining emergency medications in a manner that makes them rapidly available, the facility could not assure they were ready for an emergent situation. The failed practice had the likelihood to affect all patients who needed emergency medications. Finding follow:

A. Record review of the "Rules and Regulations for Hospitals and Related Institutions in Arkansas (2016), Section 12.S.4," showed emergency type medications were to be secured with a breakaway seal.
B. During a tour of Surgical Services on 12/03/18 from 2:20 PM until 3:17 PM; observation showed the [DIAGNOSES REDACTED] emergency cart was unlocked and it was not secured with a breakaway seal.
C. During an interview on 12/03/18 at 2:42 PM, the Director of Operating Room and Infection Preventionist verified the emergency [DIAGNOSES REDACTED] medications were being stored in a cart that was not secured.

Based on review of policy, Daily Temperature Record and interview, it was determined the facility failed to adhere to acceptable professional standards in that they did not take steps to notify the Pharmacist when the medication refrigerator temperatures were too cold for 24/43 shifts in one (Emergency Department) of three (Emergency Department, Medical Surgical and Surgical Services) areas toured. By not having taken steps to notify the Pharmacist, the refrigerator continued to store medications and biologicals too cool. The failed practice had the likelihood to affect all patients that were to receive medications out of the medication refrigerator. Findings follow:

A. Review of the facility's policy titled, "Temperature Control for Refrigerator and Freezer," dated 06/2017, showed the medication refrigerators' temperature range is 36 to 46 degrees Fahrenheit. The policy also showed pharmacy is responsible for filling out a variance report should the temperature fall out of the range.
B. Review of the Daily Temperature Record for 11/12/18 AM shift through 12/03/18 AM shift, the following shifts showed to be below the 36-46 degree Fahrenheit temperature range: 11/14/18 AM & PM, 11/15/18 AM, 11/18/18 AM, 11/19/18 AM, 11/21/18 AM & PM, 11/24/18 AM, 11/25/18 AM, 11/26/18 AM & PM, 11/27/18 PM and 1128/18 AM through 12/03/18 AM.
C. During an interview on 12/03/18 at 3:24 PM, the emergency room Registered Nurse Practitioner verified the dates that the temperatures were below range, and that there was no documentation the Pharmacist was notified.

Based on review of policy, observation and interview, it was determined the facility failed to adhere to accepted professional standards in that they did not follow their policy for storage of fluids in warmers in one (Surgical Services) of one unit toured that stored irrigation solutions in a warmer. By not following policies for storage, the facility could not assure the safety and efficacy of the solutions available for patient use. The failed practice had the likelihood to affect all patients that have had procedures in the facility that required warm fluids. Findings follow:
A. Review of the facility's policy titled, "Fluid Warmer," revised on 08/31/07, showed the fluids should be marked with the date of insertion into the warmer, to identify when they should be removed from the warming cabinet.
B. During a tour of Surgical Services on 12/03/18 from 2:20 PM to 3:17 PM, observation showed the following being stored in warmers in Surgical Services:
1. Operating Room Supply warmer #1 - 1000 ml (milliliter) bottle of Sodium Chloride for irrigation, not labeled with the date of insertion into the warmer; and
2. Post-Acute Care Unit warmer #1 - 1000 ml (milliliter) bottle of Sodium Chloride for irrigation, not labeled with the date of insertion into the warmer.
C. During an interview on 12/03/18 at 2:54 PM, the Director of Operating Room and Infection Preventionist verified the fluids were stored without being dated.

Based on observation, review of manufacturer's recommendations and interview, it was determined the facility failed to follow manufacturer's recommendations regarding Normal Saline Intravenous (IV) Flush Syringe storage in one (Medical/Surgical) of three (Emergency, Surgical Services and Medical/Surgical) areas toured. By not following manufacturer's recommendations for storage, the facility could not assure the safety and efficacy of the medications. The failed practice had the likelihood to affect all patients that receive medications. Findings follow:
A. Review of manufacturer's recommendations for the storage of Normal Saline IV Flush Syringes showed they were to be stored at room temperature.
B. During a tour of the Medical/Surgical unit on 12/03/18 from 1:25 PM to 2:15 PM observation showed a blanket/fluid warmer with #10 Normal Saline IV Flush Syringes 10 milliliters being stored in it.
C. During an interview on 12/03/18 at 2:03 PM, the Director of Nursing verified the findings at B.
VIOLATION: POLICIES - INFECTION CONTROL Tag No: C0278
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation and interview, it was determined the facility failed to ensure the cleanliness of the facility in that rooms designated as clean and ready for patients were not clean and one of one Clean Linen Room had trash under the supply cart. Failure to ensure patient rooms and the Clean Linen Room was devoid of trash did not ensure a clean and sanitary environment for patients. The failed practice had the potential to affect any patient placed in the affected rooms and those patients whose medical supplies and linen were housed in the Clean Linen room. Findings follow:

A. Observations in Room 11 at 1:45 PM on 12/03/18 showed a dead grasshopper and multiple dead, small, black bugs with wings, on the bathroom floor. During an interview with the Director of Nursing (DON) at 1:45 PM on 12/03/18 the above findings were verified.

B. Observation in Room 16 at 2:00 PM on 12/03/18 showed a live spider on the wall above the intravenous pump pole and the bedside chair. Observation showed the nurse call button was covered with an EKG (electrocardiogram) lead. The DON stated the room was clean and ready for a patient during an interview at 2:00 PM on 12/03/18. During the same interview the DON stated the EKG lead was placed over the call light so the previous patient, discharged on [DATE], could feel the nurse call button. The EKG lead was not removed in the cleaning of the room.

C. Observation in the Clean Linen Room at 2:10 PM on 12/03/18 showed clear plastic wrappers, bits of paper, dead bugs, and a white bowl with an unattached lid on the floor underneath the clean supply cart. During an interview with the DON at 2:10 PM on 12/03/18 the above findings were verified.


Based on policy and procedure review, observations and interview, it was determined the facility failed to ensure an organized, vigilant and effective infection control program was in place to identify, report and prevent situations in that environmental rounds were not organized, performed and the findings reported. The failed practice had the potential to allow unsafe, unsanitary and contaminated patient care items to be used in patient care. The failed practice had the potential to affect every patient whose care required the use of the medical supplies in the exterior Supply Room. Findings follow:

A. Review of the policy and procedure titled "Dissemination of Infection Prevention Information," received 12/04/18, showed the Infection Preventionist was responsible for surveillance, monitoring and reporting of infection control issues, concerns, and information to appropriate individuals, departments and/or agencies. Review of the above policy and procedure showed recommendations from the Infection Committee, changes in policies and findings of their department's environmental rounds were to be reported to Department Heads. Department Heads were responsible for helping to ensure a clean and sanitary environment for patients, visitors, and staff.

B. Review of the policy and procedure titled "Environmental Criteria," received on 12/04/18, showed ceiling tiles were to be replaced as soon as repair work is completed. In patient care areas, a temporary cover was to be placed (plastic sheeting) over the opening to avoid mold/fungi falling into the environment, that ceiling tiles should be replaced when wet, stained or damaged.

C. Observation in the exterior Supply Room at 1:35 PM on 12/06/18 showed the following:
1) Observations above the first section of supply shelving, located on the exterior wall adjacent to the door, showed the four of seven ceiling tiles were bulging downward and discolored with multiple sizes and variations of color ranging from light brown to black. Examples of medical supplies stored underneath the stained and bulging ceiling tiles included one case of graduate pitchers, two cases of Y Blood sets, one case of Buretrol Add-on Sets, two boxes of Clearlink Conti-flo Solution Sets, three boxes of Medline 25 gauge Safety Needles.
2) Observations on the end wall between the first and second sections of shelving included a six inch hole in the concrete block wall that was stuffed with blue paper and then painted over. Observation of the light fixture between the first and second sections of shelving showed a discolored tile on either side of the fixture.
3) Observations on the second section of supply shelving showed five of seven ceiling tiles discolored with multiple sizes and variations of color ranging from light brown to dark brown. Observations at the end of the second section, showed a 12 inch by 12 inch opening in the wall that bordered the ceiling. Examples of medical supplies stored underneath the stained and bulging ceiling tiles included one case of elastic bandages, one box of Snugfit fitted stretcher sheets, one case of laceration trays, one case of pediatric ambu bags, two cases of adult ambu bags, one box containing ten anesthesia circuits and one box containing twenty anesthesia circuits, respiratory therapy supplies that included one box of CO2 (carbon dioxide) nasal samplers, one case of Bitrac ED mask and one box of Incentive Spirometers.
4) Observations on the back wall of the Supply Room showed an AC unit mounted at the ceiling. The AC unit was covered in black grime, spider webs, and dust.
5) Observations in the far right corner of the room showed a heating unit suspended from the ceiling. Observation of the ceiling tiles immediately in front of the heater showed multiple sizes and variations of color ranging from light brown to dark brown stains. During an interview with the Central Sterile Supply Technician from 1:30 PM to 2:30 PM on 12/06/18 the findings in D were verified.

D. The Infection Control Nurse stated during an interview at 2:20 PM on 12/06/18 that she had not been conducting environmental rounds and had not been in the exterior supply room since appointment to the Infection Control Nurse position in August or September of 2017.

E. During a tour of the exterior Supply Room with the Director of Nursing (DON) at 8:40 AM on 12/07/18, she stated she only ran out to the Supply Room to get a supply item when the nurses were busy.

F. During an interview with the Maintenance Director at 10:30 on 12/07/18, he presented the environmental rounding sheets, dated 10/27/17 in the Rural Health Clinic, 11/28/17 in the Radiology Department, and 11/30/17 in the Operating Room. The Maintenance Director stated the Department Head for the department being rounded on each month was to accompany him in the rounding of their department. The Maintenance Director stated the above roundings were the last environmental rounds he had completed.


Based on policy and procedure review, Department Head and Committee of the Whole meeting minutes, and interviews, it was determined the facility failed to ensure the required representation participated in the Infection Control Committee, and that indicators, benchmarks and monitoring schedules for the aspects of surveillance and prevention of infections were established. The failed practice did not assure the facility had an effective, functioning Infection Control Program. The failed practice had the potential to affect all patients, staff and visitors. Findings follow:

A. Review of the policy and procedure titled "Infection Prevention Plan," received 12/04/18, showed the Infection Prevention Program was to be a hospital wide program which was responsible for the monitoring and evaluating of infections, infection prevention practices, the identification of risks for the acquisition and transmission of infectious agents, the implementation of corrective actions, the evaluation of outcomes, the redesign of patient care processes as indicated and the appropriate reporting to hospital and professional staff. Review of the above policy and procedure also showed the Infection Prevention Program was to include representation from Infection Prevention, Radiology, Materials Management, Laboratory/Pathology, Clinical Services, Pharmacy, Environmental Services, Engineering Services, Dietary, Administration, and the Medical Staff. Review of the policy and procedure showed the Infection Control Committee was to determine the indicators, benchmarks, and monitoring as well as the scheduling of them. The policy and procedure stated a summary of problems, actions taken and results of those actions were to be included in the reporting process as appropriate.

B. Review of the policy and procedure titled "Dissemination of Infection Prevention Information," received 12/04/18, showed the Infection Preventionist was responsible for surveillance, monitoring and reporting of infection control issues, concerns, and information to appropriate individuals, departments and/or agencies. Review of the above policy and procedure showed recommendations from the Infection Committee, changes in policies and findings of their department's environmental rounds were to be reported to Department Heads. Department Heads were responsible for helping to ensure a clean and sanitary environment for patients, visitors, and staff.

C. The Infection Control Nurse stated during an interview at 3:05 PM on 12/04/18, there were no committee meetings for Infection Control, the Committee of the Whole was the only committee she was aware of.

D. During an interview with the Chief Executive Officer at 9:00 AM on 12/07/18, she stated the Infection Control Nurse reported at the Department Head Meeting held every two weeks.

E. Review of the bi-weekly Department Head Meeting Minutes from 07/26/18 through 11/29/18, received on 12/06/18, showed the following Infection Control Reports:
1) 07/26/18 - nothing recorded.
2) 08/14/18 - "TB (tuberculosis) and Fit test."
3) 08/23/18 - "still getting TB and Fit done."
4) 09/20/18 - "Good."
5) 10/04/18 - "highly encourage depts. (departments) to get shot or sign the form. Documentation if you get a shot somewhere else."
6) 10/18/18 - nothing recorded.
7) 11/01/18 - "Good."
8) 11/15/18 - "All good. Busy yesterday."
9) 11/29/18 - "Reported on IC (Infection Control) No problems at this time.

F. During an interview with the Infection Control Nurse at 11:05 AM on 12/07/18, she stated there was not an Infection Control Committee, only a Committee of the Whole. The Infection Control Nurse stated she was not aware Infection Control Policies and Procedures outlined duties that were to be performed by the Infection Control Committee such as indicators selected, thresholds established, and schedules for reporting, monitoring and surveillance. The Infection Control Nurse stated there were no indicators selected, no thresholds established, and no schedules for monitoring/surveillance.

G. Review of the Committee of the Whole Meeting Minutes revealed an Infection Control report was not presented at the Committee of the Whole Meeting Minutes for four (05/08/18, 06/12/18, 07/17/18, 08/14/18) of seven (03/20/18 - 09/11/18) months.


Based on Centers for Disease Control (CDC) guidelines, observation and interview, it was determined the facility failed to identify and control the spread of infections in that it failed to assure laryngoscope blades in the Anesthesia Cart in Operating Room #1 were packaged and stored in a manner to prevent contamination. Failure to assure clean, uncontaminated equipment was available for patient care had the potential to allow cross contamination between patients. The failed practice had the potential to affect all patients whose care required the use of the laryngoscope blades in the post-operative area. Findings follow:

A. Observation at 2:17 PM on 12/03/18, in the top drawer of the Anesthesia Cart, showed the following laryngoscope blades lying loose, unpackaged and in contact with each other, ring forceps, forceps and other items in the drawer: two Mac 3 with handles, and one Mac 3.5. Also in the drawer was a clear, plastic bag which contained eight blades that were not individually packaged and two blades in an open, plastic container. During an interview, the Director of the Operating Room verified the above findings at 2:17 PM on 112/05/18.

B. Review of the facility's selected recognized guidelines (CDC), showed it was a recommendation for laryngoscope blades to be stored in individual packages to minimize the potential for cross contamination. During an interview at 3:05 PM on 12/04/18, the Infection Control stated the facility utilized the CDC and APIC (Association for Professionals in Infection Control and Epidemiology) guidelines.




Based on review of policy, review of Healthcare Workers' TB (Tuberculosis) records, and interview, the Infection Control Officer failed to identify that one (#7) of seven (#1-#7) Physicians; one of one (#1) Dentists; and one of one(#1) Speech Language Pathologists (SLP) were not being screened annually for TB. By not assuring the Healthcare workers were screened annually, the facility could not assure they were controlling infections and communicable diseases of patients and personnel. The failed practice had the likelihood to affect all of the employees and patients in the facility. Findings follow:

A. Review of the policy titled, "Employee Health Screening for Tuberculosis (TB)," showed all employees were to be tested and or screened for TB upon hire and annually thereafter.
B. Review of the Healthcare Workers' Tuberculosis records showed the following:
1) Physician #7 was last screened on 05/18/17 and was due for rescreening on 05/18/18;
2) Dentist #1 did not have any records of TB screening in their records; and
3) SLP #1 did not have any records of TB screening in their records.
C. During an interview on 12/07/18 at 9:40 AM, the Chief Executive Officer verified the findings at B.

Based on review of policies, review of cleaning lists for the hydrocollator (stores and heats hot packs) and interview, it was determined the Infection Control Officer failed to identify that Rehabilitation Services was not cleaning the hydrocollator on a monthly basis (per policy) in one of one (outpatient) rehabilitation gyms toured. By not cleaning the hydrocollator per policy, the facility could not assure the sanitary environment when patients used these items. The failed practice had the likelihood to affect all rehabilitation patients who received hot pack therapy. Findings follow:

A. Record review of the facility's policy titled, "Cleaning Equipment," revised 10/09/17, showed the hydrocollator was to be cleaned monthly.
B. Review of cleaning lists showed the last documented date the hydrocollator was cleaned was 05/02/17.
C. During an interview on 12/04/18 at 11:00 AM, the Director of Physical Therapy verified the findings at B.




Based on observation and interview it was determined the Infection Control Officer failed to ensure a sanitary environment in that the septums of vials of Demerol and Versed were not cleaned prior to delivery into the IV (Intravenous) of Patient #23. The failed practice did not provide aseptic technique and did not ensure the vials were free of contaminants The failed practice affected Patient #23 and created the likelihood to affect all patients. Findings follow.

A. On 12/03/18 at 10:49 AM it was observed RN (Registered Nurse #1) failed to clean the septum of one vial of Versed on one of one entry and one vial of Demerol on one of one entry for the delivery of IV medications.

B. During interview on 12/03/18 at 11:20 AM, RN #1 verified the above findings.
VIOLATION: SURGICAL SERVICES Tag No: C1140
Based on observation, document review, and interview, it was determined the facility failed to meet the Condition of Participation for Surgical Services in that the facility failed to:
1) Ensure Cidex OPA test strips were dated when opened, perform the Quality Control test when a new bottle of Cidex OPA test strips were opened and failed to monitor the temperature of the room the Cidex OPA test strips were stored.
2) Ensure staff facial and head hair was covered while performing and assisting in a sterile, surgical procedure, failed to ensure food items were not allowed into the sterile environment of an operating room, and failed to ensure sterile packs were not placed in an area where they could be contaminated by water.
3) Ensure one of the eleven required elements were included in the Operating Room Log.
4) Ensure the facility developed and implemented a policy and procedure outlining the facility's policy on the Do Not Resuscitate status of patients undergoing a surgical procedure.
5) Ensure a dedicated Registered Nurse was available to perform the role of Circulating Nurse during an endoscopy procedure.


Based on policy and procedure review, review of manufacturer's instructions, observation and interview, it was determined the facility failed to prevent and control the spread of infection in that the Cidex OPA test strips were not dated when opened, the Quality Control Procedure to check the effectiveness of the Cidex OPA test strips was not performed at the opening of each new bottle in two of two units (Central Sterile and Scope Room) and the temperature of the two units was not monitored to ensure the Cidex OPA strips were stored at a temperature of 15 - 30 degrees Centigrade. Failure to date the Cidex OPA test strips when opened, failure to perform the Quality Control Procedure when each new bottle was opened, and failure to store the strips at the recommended temperature did not ensure the accuracy of the strips and did not guarantee the accuracy of the daily checks of the Cidex OPA Solution. The failed practice had the potential to affect all patients whose care required high level disinfected equipment. Findings follow:

A. Review of the policy and procedure titled High Level Disinfection with Cidex OPA, received on 12/04/18, showed the Cidex OPA Solution was to be checked with a test strip prior to each use to ensure the solution was at a minimum effective concentration (MEC). If the MEC was not present, the solution was to be discarded and fresh solution was to be obtained. Review of the policy and procedure also showed the date the bottle of strips were opened were to be recorded on the strip bottle as the strips were not good after 90 days of opening. Review of the policy and procedure showed the Quality Control (QC) test was to be performed each time a new bottle was opened and if the QC test results showed the strips were not functioning properly, the remaining strips were to be discarded.

B. Review of the manufacturer's instructions located on the Cidex OPA Strip bottle showed the strips were good for 90 days after opening and the strips should be stored at a temperature of 15-30 degrees Centigrade.

C. Observation in the Central Sterile Room at 2:15 PM on 12/03/18 showed one bottle of Cidex OPA Strips were not dated when opened and the temperature of the room was not monitored.

D. Observation in the Scope Room at 2:30 PM on 12/04/18 showed the bottle of Cidex OPA strips were not dated when opened.

E. During an interview with the Director of the Operating Room at 2:30 PM on 12/04/18 she verified the findings in B, C, and D.


Based on policy and procedure review, observation and interview, it was determined the facility failed to ensure the cleanliness of the operating suite and the sterility of sterilized equipment in that it failed to assure facial and head hair was covered in five (Physicians #1 and #2, Infection Control Nurse, Registered Nurse (RN) #1, and the Director of the Operating Room (OR) of six (Physicians #1 and #2, Infection Control Nurse, Registered Nurses (RN) #1 and #2, and the Director of the OR) operating room staff, drink containers were not allowed in the operating room, and sterilized packs were not placed in a sink. Failure to ensure facial and head hair was covered and drink containers were not allowed in the operating room had the potential to allow contamination of the operative site and suite; failure to ensure sterilized packs of instruments were not placed in a sink had the potential for the packs to become wet therefore contaminated. The failed practice had the potential to affect Patient #22 on 12/05/18 and any patient whose surgical procedure required the use of the colposcopy set and hand retractor. Findings follow:

A. Review of the policy and procedure titled "Attire in Restricted and Non-Restricted Areas," received on 12/04/18, showed all personnel must cover head and facial hair when in the semi-restricted and restricted areas of the operating room.

B. Observation during the surgical procedure for Patient #22 at 9:00 AM on 12/04/18 in OR #1 showed Physician #1 who was performing the surgery, with facial hair uncovered from the edge of the mask to both ears, Physician #2 with one inch of hair uncovered at the nape of the neck from ear to ear, the Infection Control Nurse and Registered Nurse #1, who were both assisting with the surgical procedure, with wisps of hair uncovered at the nape of the neck, and the Director of the Operating Room with one inch of hair uncovered from ear to ear at the nape of the neck. The Director of the Operating Room verified the above findings in an interview at 10:16 AM on 12/05/18.

C. Observation during the post-operative cleaning of OR #1 showed a large mug, about 8 inches tall, labeled "Bubba," containing approximately 3-4 ounces of a dark brown/black liquid, sitting on the second shelf of a metal cart behind and to the right of the anesthesia machine. During an interview with the Director of OR at 10:40 AM on 12/06/18 she stated the mug belonged to Physician #2.

D. Observation in the Central Sterile Room at 2:15 PM on 12/04/18 showed a Colposcopy set and a hand retractor wrapped in muslin, sitting on a rack, in a functional sink. During an interview with the Director of the OR at 2:25 PM on 12/04/16, she stated the instruments were being temporarily stored on the rack in the sink, prior to obtaining the biological indicator results for the sterilizer used.





Based on review of the operating room register and interview, it was determined the facility failed to include 1 (patient age) of the 11 required elements on the operating room log. Failure to include all of the required elements in the operating room log did not allow the facility to track and trend potential problems. Findings follow:

A. Review of the operating room register revealed it did not contain documentation of the patient's age.

B. The above findings were verified by the Director of the Operating Room at 1:00 PM on 12/04/18.

Based on interview and Policy and Procedure Manual review, it was determined the facility failed to develop and implement a policy and procedure addressing the Do Not Resuscitate (DNR) status of operative patients. Failure to develop and implement a policy and procedure addressing the DNR status of operative patients did not allow the surgeon, the surgical services staff, patients and family members to be knowledgeable, accepting and approving of what steps would be undertaken in the event of the cardiac or respiratory arrest of a patient during surgery. Findings follow:

A. Review of the Surgical Services Policy and Procedure Manual revealed there was no policy or procedure that addressed a surgical patient's DNR status.

B. During an interview with the Director of Operating Room on 12/06/18 at 1:05 PM, she stated the facility did not have a policy and procedure which addressed the DNR status of the operative patient.


Based on observation and interview it was determined the facility failed to ensure a dedicated Registered Nurse (RN) was available to perform the role of a Circulating Nurse during one of one Endoscopy procedures. The failed practice did not ensure that a dedicated RN was available during the procedure to perform as the Circulating Nurse who would manage the surgery room and immediately be available to intervene and provide care if needed. The failed practice affected Patient #23. Findings follow:

A. During observation on 12/05/18 at 10:40 AM the staff for the Endoscopy procedure included Licensed Vocational Nurse (LVN) #1 and Registered Nurse (RN) #1. LVN #1 remained at the head of the bed. RN #1 administered medication one of one Versed at 10:47 AM and one of one Demerol at 10:49 AM, and assisted the physician with obtaining biopsy specimen and labeling.

B. During an interview with RN # 1 she stated she did administer medications, observe patient and assist with receiving biopsies and labeling specimens. She also stated there was no Circulator Nurse RN in the Endoscopy procedure of Patient #23.

C. Findings in A and B were verified on 12/05/18 at 11:20 AM with RN # 1.
VIOLATION: SNF SERVICES Tag No: C1608
Based on policy and procedure review, and interview, it was determined the facility failed to have a process in place to assure two of two (Patient #1 and #2) Swing Bed Patients were allowed to use and keep personal possessions, and failed to have a process in place to allow Swing Bed patients who wanted to work, could work and Swing Bed patients who did not want to work, were not forced to work for the facility. Failure to put in place a mechanism to ensure Swing Bed Patients could use and retain their personal possessions, failure to have a process which specified the right for a Swing Bed Patient to choose to work, or chose not to work, did not assure the Swing Bed Patients were knowledgeable of and assured of their patient rights. The failed practice had the potential to affect Swing Bed Patient #1 and #2. Findings follow:

The Director of Nursing stated during an interview at 8:30 AM on 12/07/18, that she was not aware there should have been a process that ensured Swing Bed Patients could keep and use their personal possessions while a Swing Bed Patient, and that Swing Bed Patients had the right to work or refuse to work for the facility.