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 observation, document review, and interview the facility failed to ensure a clean and sanitary environment was provided to control and prevent the possible transmission of infections in 14 (emergency room (ER) Waiting Room, ER Hallway, ER Clean Equipment /Storage Room, Clean Patient Supply/Storage, Main ER Area/Nurses Station, ER Patient Room #3, ER Medication Room, OB/GYN Room, Fast Track Area/Patient Restroom, ER Patient Room #14, ER Patient Room #4, Intensive Care Unit (ICU) Patient Room #3, ICU Medication Room, and ICU Patient Nutrition Room) of 14 areas observed.

Findings Include:

An observation tour was conducted on 1/21/2020 after 10:00 AM with Staff #3, #4, #8, and #10 the following was observed


Sterile instruments in peel packs were stored on the floor in a blue bin with unsterile items. The bin was covered with dirt dust and debris. There was unsterile supplies stacked on top of sterile surgical instrument trays placing the sterility of the items at risk of puncture and contaminating the instruments within. The bottom shelf on the metal rack used for storage was covered with dirt, dust, and debris. The vent in the ceiling was covered with dark dust that spread onto the tile surrounding the vent.

A small closet was inside the storage room that was being used to store patient equipment. There was no identifier found on the equipment to determine if the equipment was clean or dirty. The wall was noted to be missing tile and exposing the sheetrock. The floor was missing tile and heavily covered with dirt, dust, and debris.


The wall behind the door was noted to be missing paint and exposing the sheetrock. The corner of the wall next to the long electrical strip was missing paint and had large gouges in the wall exposed the sheetrock. The sheetrock could not be properly sanitized to prevent possible transmission of infections. Inside the cabinet above the sink were four gray, four purple, and one blue top lab tubes used to collect blood from a patient were found to be expired. The gray top tubes had an expiration date of 8/31/2018. The four purple top tubes had an expiration date of 2/28/2018. The blue top tube had an expiration date of 3/31/2019. The expired blood tubes could give an inaccurate lab result resulting in patient harm or even death. The bottom shelf of the cabinet was soiled with a reddish-brown colored dried substance.

An interview was conducted with Staff #10 on 1/21/2020 after 10:00 AM. Staff #10 was asked if she was aware the lab tubes were expired and who was responsible to check for expired items. Staff #10 replied, "The nurses are responsible for checking to make sure that no supplies are expired."

Staff #8 and #10 confirmed the findings.


The sink in the medication room was soiled with a white stain. The counter top was noted to be missing part of the laminate exposing the porous surface. The porous surface could not be properly sanitized to prevent cross contamination. The inside of the cabinet under the counter was covered with heavy dirt, dust, and debris and was noted to store patient supplies. Next to the sink, on the floor a biohazard bin was left open and trash was noted on the top. The floor in front of the biohazard bin was missing tile exposing the concrete. The biohazard bin hanging on the wall was visibly noted to be soiled with dark reddish-brown stain on the front surface. Staff #10 confirmed this finding and could not state what the dried substance was on the wall mounted biohazard bin. Behind the trash can was a hole in the wall that was about 5 inches in length. It was exposing the sheetrock and could not be properly sanitized.

Staff #10 was asked if she was aware of the damage to the wall. Staff #10 stated, "Yes and it's in our plan for renovation but the door hits the trash can and the trash can hits the wall."


The toilet was still holding yellow urine and toilet tissue. To the left and right of the toilet near the floor the tile was soiled and was missing pieces exposing the concrete below. Behind the toilet was dirty and the tile was pushed into the wall leaving an opening into the bathroom. The opening would allow for insects or small rodents to enter through the wall.


Staff #4 and #9 confirmed the room was clean and ready for a new patient. The fitted sheet on the bed was noted to have a long tear in it. There was human hair noted on the sheet.


Inside the medication room the floor was visibly soiled with heavy dirt, dust, debris, and human hair. The freezer in the medication refrigerator needed to be defrosted. The bottom shelf was dirty with dust and debris.


The wall behind the sink had a brown stain within the caulking along the base where the wall and countertop connect. Brown stains in the corner of the wall on the countertop were also observed. The cabinets above the sink were missing paint around the handles. The floor between the refrigerator and the wall was very heavily soiled with dirt, dust, debris, and a black dust particle. The wall behind the large trash can was missing paint and had chips in the wall exposing the porous surface underneath. In the freezer of the large stand up refrigerator human hair was noted next to patient nutrition. The countertop next to the coffee maker was covered with a white substance that appeared to be sugar. Below the coffee maker inside the drawer was several dried liquid brown spots.

Staff #4 and #9 confirmed the findings.

A review of ANSI/AAMI ST79:2017 revealed the following:

"...11 Storage and transportation

11.1 Sterile storage

11.1. Storage facilities

Sterile items should be stored under environmentally controlled conditions in a manner that reduces the
potential for contamination.

Sterile storage areas should be kept clean and dry.

Sterile items should be
1) stored far enough away from the floor, the ceiling, and outside walls to allow for adequate air circulation, ease of cleaning, and compliance with local fire codes;

2) stored at least 8 to 10 inches above the floor, at least 18 inches below the ceiling or the level of the sprinkler heads, and at least 2 inches from outside walls;

3) stored in such a way that wrapped packages are not stored beneath rigid sterilization containers on the same shelf; and

4) positioned so that packaging is not crushed, bent, compressed, or punctured and so that their sterility is not otherwise compromised..."

An interview was conducted with Staff #8 on 1/21/2020 after 10:00 AM. Staff #8 was asked if there was regular scheduled Infection Control Rounds. Staff #8 stated, "Yes we make EOC rounds weekly in different areas of the hospital." Staff #8 was then asked who was responsible to ensure any problems noted on the rounds were corrected. Staff #8 said, "We send the deficiencies to the Department Directors and they are the ones who ensure the areas are addressed."

A review of the document titled, "EOC Rounds ED 11/01/2019" revealed:

" ...2. Location: Minor ED Treatment room; Findings: Recliners x2 with tears; Department Staff #10; Work orders Date: (blank); Project date: (blank) Date Completed: (blank) Notes: will notify Staff #10 to order new recliners.

3. Location: Several ED Rooms; Findings; Linen containers with rust and stained tops; Department Staff #10; Work orders Date: (blank); Project date: (blank) Date Completed: (blank) Notes: will notify Staff #10 to order new linen carts ...

8. Location: Hallway Findings; Large supply cart in hallway with clean supplies; Department: Staff #10; Work orders Date: (blank); Project date: (blank) Date Completed: (blank); Notes: Does not look neat and clean supplies exposed to visitors and patients.

12. Location: Findings: Floors throughout the ED look dull and in some places, dirty. Department: EVS Work Orders Date: (blank); Project date: (blank) Date Completed: (blank); Notes: (Blank) ..."

Staff #8 confirmed the supply cart in the hallway with clean supplies and the floors are still a deficient finding on this current survey.

Staff #3, #4, #8 and #10 confirmed the findings.

A tour of the emergency room Services was performed on 1-21-2020 in the afternoon with Staff #3, #4, #8, and #10.

ER Waiting Room-
Two sinks were out of order with soiled paper signs laid across. The sinks were stained with coffee and dust.
4 chairs were found torn and exposing the inner cushions.
10 chairs were found soiled with food, paper candy wrappers down the sides, dirt, sticky substances spilled on them, and dust.
The floor was heavily soiled with dirt, dust and hair. Spilled dried liquids were found spilled on the floor and under the chairs along with food particles. Staff # 3 confirmed the findings.

ER Hallway-
In the hallway sitting next to the ambulance bay doors was a metal rolling shelf filled with opened patient medical supplies. The cart was not covered, and the supplies were covered in a light dust. The doors opened to the outside multiple times a day exposing the uncovered supplies. Staff #10 stated that they should have put the supplies back into the supply room after filling the rooms with needed supplies. Staff #10 confirmed the cart rolled around into various rooms and hallway, would be put back into the clean supply room.

ER Clean Equipment Storage Room-
Multiple types of equipment including a stretcher, O2 containers and metal holder, wheel chairs, restraint chair, 2-shower heads on the wall, a rolling metal tray with drawers, O2 suction on wall with canister attached, and a large, rolling, pleated, trifold room partition.
The floor was heavily soiled with dust, dirt and hair.
The room had two soiled bath towels on the floor.
The stretcher was soiled with dust, old tape residue and paper trash on top.
A rolling tray with a drawer was found to be open. Inside was blood draw supplies that were soiled with dust and dirt.
A suction canister was on the wall with a significant amount of dirt and dust on top. The surveyor was able to draw initials in the dust.
The restraint chair was soiled with dust and dirt.
A door was in the clean storage room that lead out to the ambulance bay. The side walk, and bay was covered in dirt, plastic tops for syringes, dirty gloves, ekg paper, surgical mask, leaves and multiple paper trash.
A large crack was found in the concrete floor and was covered with duct tape. The tape was heavily soiled in dirt and matter.
The trifold partition was heavily soiled with dust.
An interview with Staff #10 was conducted on 1-21-2020.Staff #10 reported that all the equipment in the room should have been clean before putting back into the room. Staff #10 confirmed the findings in the room and stated, "It needs to be cleaned."

Clean Patient Supplies Area/Storage-
The floors of the room were soiled with dirt and dust. The supply room had dirty shipping boxes sitting on the floor touching clean unpacked medical supplies.
Medical supplies were found on the dirty floor and surgical supplies were found in open containers under the medical supplies shelf on the floor. The supplies were covered in dust, dirt and hair.
4 Bed side commode chairs (BSC) that had no information if they were clean or dirty were found in the medical supply room. The BSC's were covered in old tape, rust on the legs and the lids were soiled with a dry liquid substance and dust.
Dirty shipping boxes found sitting on top of clean patient supplies.
An interview with Staff #8 and 10 was conducted on 1-21-2020. Staff #10 reported that the room was supposed to only have clean equipment and supplies. Staff #8 reported that she was not aware of the shipping boxes or surgical supplies on the floor.

Main ER Area and Nurses Station-
The patient refrigerator in the ER was heavily soiled on the outside with dust, dirt, and the handles had a black substance on the outside. The inside was soiled with dirt, hair, spilled liquids and food particles.
The paper shredder container was missing pieces exposing particle board and was unable to clean. The container had a wash basin tub sitting on top with lab supplies inside. The tub was soiled with dust.
The floors in the nurse's station were heavily soiled with dirt, dust, and hair. Trash was found on the floor and in corners and under work areas.
The trash cans in the nurse's station was heavily soiled on the outside and top with dust and dried spilled liquids.
An interview with Staff #10 was conducted on 1-21-2020. Staff #10 stated the ER had only one housekeeper for all the patient rooms, storage areas, waiting rooms, and nurses station.

ER Patient Room 3- (The room was a terminally clean room and ready for a patient.)
Had soiled floors with dust, dirt and hair. The drawers were pulled open and medical supplies were sitting in dust and hair.
The cabinet under the sink had a lock but was not locked. The cabinet was heavily soiled with dirt and dust.
The open cabinets were missing Formica exposing particle board, the shelves had a buildup of old tape residue catching dust and hair where clean medical supplies were sitting on.
The trash cans still had trash in them. The biohazard trash was also holding trash.
Leads that went from the heart monitor to the patient was found hanging and dragging the soiled floor.
The mattress underneath the stretcher was soiled and had not been wiped down including the bed frame. Crayons were found stuffed down into the bed frame.
An uncovered pillow was found sitting on the bed frame under the head of the mattress. When the pillow was picked up the bed frame was soiled with dust, dirt, and paper trash.

ER Medication Room-
A plastic container holding medications had 12 sections. Each section was heavily soiled with dust, dried spilled liquids, old tape, and debris.
A container of blood supply items was found stored in an open container by the sink. It was confirmed that this container does not leave the med room and sits in this spot. To wash your hands, you must reach over the open box to get a paper towel. All the wet hands drip into the supply box soiling the blood supply products. There was no divider between the sink and supplies to avoid splash.

A table top eye exam device was found next to the stretcher uncovered and soiled with dust and hair.
The outside of the pelvic box was found to be heavily soiled with tape residue, dust, and dirt.

Fast Track Area-
3 reclining chairs were found ripped and stacked to be discarded but were in the room where patients are treated.
The rolling holder for the vital sign equipment was found to be soiled with dust and trash.
Three soiled linen holders were found to be heavily soiled on the top with dust, dirt, debris and rust. The sign on the top said isolation linen but they were in non-isolation rooms.

ER Patient Room 14-
Multiple blood tubes were sitting in soiled blood trays. The trays were soiled with dust and old tape.