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Based on observation, interview, and record review the facility failed to ensure the Condition of Participation for Governing Body was met as evidenced by:

1. The Governing Body failed to develop and implement a plan to ensure the facility's roof was maintained to prevent water intrusion (unwanted movement of water or vapor into a building. This can cause damage to the building's structure and material) and the development of a mold (a type of fungus that develops on organic matter that is either damp or rotting) -like substance in the Radiology Office and adjacent areas of the hospital and failed to mitigate or abate the mold-like substances. This deficient practice resulted in the water damage and the growth of a mold-like substance in the Radiology room and adjacent rooms, and had the potential for patients, staff, and visitors to be exposed to mold. (Refer to A077)

2. The Governing Body failed to ensure the facility ' s contracted construction company maintained or repaired the facility ' s roof to prevent water intrusion and the development of a mold-like substance in the Radiology Office and adjacent areas of the hospital and failed to mitigate or abate the mold-like substances. This deficient practice resulted in the water damage and the growth of a mold-like substance in the Radiology room and adjacent rooms and had the potential for mold to spread to adjacent areas of the hospital and compromise patient, staff, and visitor's safety. (Refer to A083)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare in a safe physical environment.

Based on observation, interview, and record review the facility failed to ensure the Condition of Participation for Quality Assurance Performance Improvement (QAPI) was met as evidenced by:

1. The facility failed to take actions aimed at ensuring staff, visitor, and patient safety when a mold (a type of fungus that develops on organic matter that is either damp or rotting) -like substance was observed behind a ceiling tile in the Radiology Office, and adjacent rooms and failed to take actions aimed at fixing the root of cause of water intrusion and development of the mold-like substance. This deficient practice had the potential for mold exposure to staff, patients, and visitors, compromising their safety. (Refer to A283)

2. The Governing Body failed to provide adequate resources to ensure the cause of water intrusions (unwanted movement of water or vapor into a building. This can cause damage to the building's structure and material) and the development of a mold-like substance in areas of the hospital were remedied to reduce potential safety risk for patients, staff, and visitors. This deficient practice had the potential for mold exposure to staff, patients, and visitors, compromising their safety. (Refer to A315)

The cumulative effect of these deficient practices had the potential to compromise patient, staff, and visitor's safety.

Based on observation, interview, and record review the facility failed to ensure the Condition of Participation for Physical Environment was met as evidenced by:

1. The facility failed to appropriate mitigation and corrective actions to safeguard staff, 57 of 57 Patients (1 - 57), and visitors in response to mold (a type of fungus that develops on organic matter that is either damp or rotting) -like substances found in the facility's radiology office (Room 136), the radiology storage area (Room 116), the boiler room, and in the basement areas. This deficient practice had the potential for mold exposure to patients, staff, and visitors and the potential for the spread of infection. (Refer to A701)

2. The facility failed to ensure that doors to the clean linen room and storage room located on the west side of the facility were not obstructed from closing. This deficient practice had the potential for the inability to contain fire or smoke in the event of a fire. (Refer to A709)

3. The facility failed to maintain hot water plumbed to one out of one sampled sink (decontamination sink - a sink used to wash off biological materials such a flesh, blood and other materials prior to sterilization) in the Decontamination Room (room where surgical tools are cleaned). This deficient practice had the potential to result in ineffective removal of contaminants (a biological, chemical, physical or radiological substance that becomes harmful for humans or living organisms) including blood, tissue, and other hazardous materials from surgical instruments (reusable metal tools used during surgical procedures) in the decontamination sink (Refer to A722)

4. The facility failed to maintain hot water measuring higher than 120 degrees Fahrenheit (F, a unit of measuring temperature) at sinks in four out of four sampled patient rooms (Room 10, Room 12, Room 26, and Room 34). This deficient practice had the potential to result in Severe burns from to patients and visitors using the bathroom sinks. (Refer to A722)

5. The facility failed to maintain operating room doors, vent grille, heating ventilation air conditioning (HVAC) systems, light fixtures, a sewer line, cement foundation beneath a boiler, and areas of the hospital free from water damage. This deficient practice had the potential to negatively affect patients', staff, and visitors' health and safety. (Refer to A724)

6. The facility failed to maintain sensitive areas including the Operating Room (OR), the Decontamination Room, and sterile holding areas with proper temperature, relative humidity (the amount of water vapor present in air) levels and air pressure levels. This deficient practice had the potential for microbial growth to occur on the sterile instruments and for microbes to spread in sterile areas resulting in increased infections and risk to patients receiving surgical services. (Refer to A726)

The cumulative effect of these deficient practices had the potential to negatively affect the patients, staffs and visitors' health and safety.

Based on observation, interview, and record review the facility failed to ensure the Condition of Participation for Infection Control was met as evidenced by:

1. The facility failed to develop and implement policies and procedures related to the storage of surgical scrubs (a protective garment designed to be worn by the doctor, nurse, and others in the operating room), patient gowns, and clean linen. (Refer to A772)

2. The facility failed to ensure the facility followed infection control policies and procedures. Sterile equipment including laryngoscope (a thin tube with a light, lens, and video camera that doctors use to examine the larynx, or voice box) handles, respiratory therapy equipment, and urinary catheters (flexible tube that drains the bladder and collects urine in a drainage bag) were stored in areas that did not have temperature or humidity monitoring. The door to the decontamination room was left open in the semi-restricted area of the Surgical Suite adjacent to the operating room (OR). (Refer to A776)

The cumulative effect of these deficient practices had the potential for the spread of infection.

Based on observation, interview, and record review, the Governing Body failed to develop and implement a plan to ensure the facility ' s roof was maintained to prevent water intrusion (unwanted movement of water or vapor into a building. This can cause damage to the building's structure and material) and the development of a mold (a type of fungus that develops on organic matter that is either damp or rotting) -like substance in the Radiology Office and adjacent areas of the hospital and failed to mitigate or abate the mold-like substances.

This deficient practice resulted in the water damage and the growth of a mold-like substance in the Radiology room and adjacent rooms, and had the potential for patients, staff, and visitors to be exposed to mold.

Findings:

During an observation on 8/15/2023 beginning at 9:34 a.m., the following was observed in several areas of the facility. The Radiology Office door was closed. Radiology Technician (RADT) 1 sat in front of a computer inside the Radiology Room. The survey team observed evidence of substance accumulations of black discolorations and white fuzz, that appeared to be mold-like substances and a musty smell in the Radiology Office, in the far-right corner of the room, behind the ceiling tile. Black discolorations and water damage (cracking paint, soft drywall, musty smell) were also observed in the adjacent boiler room (wall and floor), adjacent storage room (dark room, used to storage ultrasound machine [not in use]) and the basement [southeast room used to store personnel files and payroll documents]). At 3:35 p.m., the team also observed evidence of water damage (brown stains) on ceiling tiles, that would support the mold growth to three Patient rooms for Patient 16, 17, 21, 22, 23, and 24.

During an interview on 8/15/2023 at 9:54 a.m., the Lead Engineer (LE) stated that on 8/9/2023, the facility became aware of the stains on the ceiling tiles, black discolorations and white "Spider-like nest" surrounding the pipe on the ceiling of the back of the Radiology Office, and black discolorations and water damage to the adjacent storage room, boiler room and basement. The LE stated the facility replaced two ceiling tiles and added that since 8/9/2023 there has been no action to remediate the possibility of mold in ceiling of the Radiology Office. LE stated that roof repair had been delayed and could not give a reason for the delay.

During an interview on 8/16/2023 at 8:20 am, the Director of Quality (DOQ) stated she had observed water intrusion from rainstorms since late 2022 through early 2023. The DOQ verified there was water damage and mold-like substance in radiology and adjacent rooms on 8/9/2023. The DOQ verified there was limited testing of these rooms and patient rooms were not tested/inspected for potential presence of mold.

During an interview on 8/16/2023 at 9:33 am, with the Infection Preventionist (IP), the IP stated she has observed water leaks from ceilings of the hospital for the past four (4) years. IP also said those issues were brought to the supervisor ' s attention but there was no follow up. IP also noted that she had taken pictures of rain damage to ceilings for the last 3 years and notified management. IP stated if mold was present in non-patient care areas, managers should place work orders to test areas of concern. IP also verified mold-like substance was observed on 8/9/2023 in the radiology room above the ceiling tile. IP stated air quality testing conducted on 8/9/2023 did not include the radiology room or for the mold-like substance found behind the radiology room ceiling tile but should have been tested. IP agreed that moisture or rain was the perfect medium for growing mold; she continued to say that mold could become air-borne and spread to other areas of the hospital, including patient care areas. IP validated that there was no testing done to patient rooms to verify spread of mold spores to patient rooms. IP stated it would be her practice to do a walk-through of potential rooms affected by mold but there has not been any walk-through as of now. IP stated patients at the hospital were immunocompromised (a weakened immune system) and nearly all suffered from respiratory issues; some symptoms of contact with mold would be masked by symptoms already exhibited by these patients.

During an interview, on 8/18/2023 at 2:34 p.m., with the Chief Operations Officer (COO), the COO stated the project to repair had been "ongoing for a while", and the facility had only been patching the roof in the areas where water leakage was identified.

During an interview, on 8/18/2023 at 2:34 p.m., with the Chief of Staff (COS), the COS stated the facility has had problems with water leakage during rainstorms since 2020. The COS stated the facility was patching areas of the roof as needed. The COS stated the roof repair did not happen fast enough and there were no excuses, however, there were delays related to the complexity of the roof and necessary equipment.

Per report titled "Limited Indoor Air Quality Assessment", inspection date of 3/30/2023, eight organisms resulted on 4/10/2023 report, the Radiology Office, Radiology's Directors office, corridor near the radiology office and near the main lobby and outside the building. There was no evidence of testing in the patient rooms.

Per report titled "Limited Indoor Air Quality Assessment", inspection date 8/9/2023 and result date of 8/11/2023, indicated only limited testing was conducted to the Pharmacy storage room, main corridor near the Entrance to room 154 and front parking lot. There was no evidence of testing in radiology office, boiler room, or radiology dark room, or patient rooms.

A review of a report titled, "Governing Board Report", dated 6/6/2022, indicated "Old Business" topics included Roof repair. No other details were documented.

A review a report titled, "Old business Tracking - Q (Quarter) 2, Governing Board Meeting", dated 9/27/2022, indicated GB (Governing Board) recommendations for follow up included roof repair. Date to be completed: ongoing. Responsible party: Administration / Contracted construction service. Actions taken: Continue weekly update call with Director of Facilities Manager. Date Completed: Waiting for Certification.

A review a report titled, "Old business Tracking - Q (Quarter) 3, Governing Board Meeting", dated 12/13/2022, indicated GB (Governing Board) recommendations for follow up included roof repair. Date to be completed: ongoing. Responsible party: Administration / Contracted construction service. Actions taken: Continue weekly update call with Director of Facilities Manager. Date Completed: Waiting for Certification.

A review of a summary titled, "Ad Hoc Governing Board Meeting Summary", dated 4/10/2023, indicated the "Roof project is set to start in July on West wing side".

Based on observation, interview, and record review, the Governing Body failed to ensure the facility ' s contracted construction company maintained or repaired the facility ' s roof to prevent water intrusion (unwanted movement of water or vapor into a building. This can cause damage to the building's structure and material) and the development of a mold (a type of fungus that develops on organic matter that is either damp or rotting) -like substance in the Radiology Office and adjacent areas of the hospital and failed to mitigate or abate the mold-like substances.

This deficient practice resulted in the water damage and the growth of a mold-like substance in the Radiology room and adjacent rooms and had the potential for mold to spread to adjacent areas of the hospital and compromise patient, staff and visitor ' s safety.

Findings:

During an observation on 8/15/2023 beginning at 9:34 a.m., the following was observed in several areas of the facility. The Radiology Office door was closed. Radiology Technician (RADT) 1 sat in front of a computer inside the Radiology Room. The survey team observed evidence of substance accumulations of black discolorations and white fuzz, that appeared to be mold-like substances and a musty smell in the Radiology Office, in the far-right corner of the room, behind the ceiling tile. Black discolorations and water damage (cracking paint, soft drywall, musty smell) were also observed in the adjacent boiler room (wall and floor), adjacent storage room (dark room, used to storage ultrasound machine [not in use]) and the basement [southeast room used to store personnel files and payroll documents]). At 3:35 p.m., the team also observed evidence of water damage (brown stains) on ceiling tiles to three Patient rooms for Patient 16, 17, 21, 22, 23, and 24.

During an interview on 8/15/2023 at 9:46 a.m., RADT 1 stated the two ceiling tiles in the back of the room had been replaced due to discoloration.

During an interview on 8/15/2023 at 9:54 a.m., the Lead Engineer (LE) stated that on 8/9/2023, the facility became aware of the stains on the ceiling tiles, black discolorations and white "Spider-like nest" surrounding the pipe on the ceiling of the back of the Radiology Office, and black discolorations and water damage to the adjacent storage room, boiler room and basement. The LE stated the facility replaced two ceiling tiles and added that since 8/9/2023 there has been no action to remediate the possibility of mold in ceiling of the Radiology Office. LE stated that roof repair had been delayed and could not give a reason for the delay.

During an interview on 8/15/2023 at 3:04 p.m., the Director of Quality (DOQ) stated the facility became aware of mold-like substances and water damage in the Radiology Office, and adjacent areas (storage, boiler, and basement) during an inspection by the Department (Public Health) on 8/9/2023. The DOQ stated the facility was waiting for the Department ' s findings to initiate any corrective actions to the specific areas identified in the report. The DOQ stated the facility did not conduct any inspections to identify any other affected areas in the hospital, including patient rooms.

During an interview on 8/16/2023 at 8:20 am, the DOQ stated she had observed water intrusion from rainstorms since late 2022 through early 2023. The DOQ verified the roof had not been replaced and could not give a reason for the delay. The DOQ verified limited air quality testing was performed on some rooms and added that patient rooms were not tested/inspected for potential presence of mold.

During an interview on 8/16/2023 at 9:33 am, with the Infection Preventionist (IP), the IP stated she has observed water leaks from ceilings of the hospital for the past four (4) years. IP also said those issues were brought to the supervisor ' s attention but there was no follow up. IP also noted that she had taken pictures of rain damage to ceilings for the last 3 years and notified management. IP stated if mold was present in non-patient care areas, managers should place work orders to test areas of concern. IP also verified mold-like substance was observed on 8/9/2023 in the radiology room above the ceiling tile. IP stated air quality testing conducted on 8/9/2023 did not include the radiology room or for the mold-like substance found behind the radiology room ceiling tile but should have been tested. IP agreed that moisture or rain was the perfect medium for growing mold; she continued to say that mold could become air-borne and spread to other areas of the hospital, including patient care areas. IP validated that there was no testing done to patient rooms to verify spread of mold spores to patient rooms. IP stated it would be her practice to do a walk-through of potential rooms affected by mold but there has not been any walk-through as of now. IP stated patients at the hospital were immunocompromised (a weakened immune system) and nearly all suffered from respiratory issues; some symptoms of contact with mold would be masked by symptoms already exhibited by these patients.

During an interview on 8/18/2023 at 2:34 p.m., with the Chief Operations Officer (COO), the COO stated the project to repair had been "ongoing for a while", and the facility had been patching certain areas of the roof where water leakage was identified.

During an interview on 8/18/2023 at 2:34 p.m., with the Chief of Staff (COS), the COS stated the facility has had problems with water leakage during rainstorms since 2020. The COS stated the facility was patching areas of the roof as needed. The COS stated the roof repair did not happen fast enough and there were no excuses, however, there were delays related to the complexity of the roof and necessary equipment.

During an interview on 8/18/2023 at 3:16 p.m., with the Region Facility Manager (RFM) and the Senior Facility Manager (SFM) for the contracted construction company, the RFM and the SFM stated the process of replacing the roof started in 2021. The first phase of the process started in 11/2022 with work to the courtyard. The second phase would start on 8/21/2023. The RFM and SFM stated that actual roof repair had not started. The RFM and SFM were asked to provide documentation as to when the facility requested approval from the Department of Health Care Access and Information (HCAI, is responsible for the development of administrative regulations and building standards for the construction of hospitals) to repair the roof and when the request approved. The RFM and the SFM did not specify when the request was made, when the request was approved, nor did they provide any documentation from HCAI.

Per report titled "Limited Indoor Air Quality Assessment", inspection date of 3/30/2023, eight organisms resulted on 4/10/2023 report, the Radiology Office, Radiology's Directors office, corridor near the radiology office and near the main lobby and outside the building. There was no evidence of testing in the patient rooms.

Per report titled "Limited Indoor Air Quality Assessment", inspection date 8/9/2023 and result date of 8/11/1023, indicated only limited testing was conducted to the Pharmacy storage room, main corridor near the Entrance to room 154 and front parking lot. There was no evidence of testing in radiology office, boiler room, or radiology dark room, or patient rooms.

A review of a report titled, "Governing Board Report", dated 6/6/2022, indicated "Old Business" topics included Roof repair. No other details were documented.

A review a report titled, "Old business Tracking - Q (Quarter) 2, Governing Board Meeting", dated 9/27/2022, indicated GB (Governing Board) recommendations for follow up included roof repair. Date to be completed: ongoing. Responsible party: Administration / Contracted construction service. Actions taken: Continue weekly update call with Director of Facilities Manager. Date Completed: Waiting for Certification.

A review a report titled, "Old business Tracking - Q (Quarter) 3, Governing Board Meeting", dated 12/13/2022, indicated GB (Governing Board) recommendations for follow up included roof repair. Date to be completed: ongoing. Responsible party: Administration / Contracted construction service. Actions taken: Continue weekly update call with Director of Facilities Manager. Date Completed: Waiting for Certification.

A review of a summary titled, "Ad Hoc Governing Board Meeting Summary", dated 4/10/2023, indicated the "Roof project is set to start in July on West wing side".

A review of a report titled, "2022 Leadership Committee Dashboard", indicated the following:

Date (not visible on document), Quarter 4 Summary, indicated the following. Safety Management Plan Summary: December: Work to mitigate water intrusions. Recommendations, Actions & Follow-up: Continue making repairs to roof until the roof gets replaced. Responsible Party / Due date / Completion Date: Plan Operations and Director of Quality Management (DQM or DOQ), the due date or completion date was not documented.

A review of a report titled, "2023 Leadership Committee Dashboard", indicated the following:

On 4/18/2023, Quarter 1 Summary, indicated the following. Findings / Analysis: Concern over EOC (Environment of Care) leaks related to heavy rain ...Recommendations, Actions & Follow-up: Contracted Construction Company (CCC) continue to focus on patch repair and roof project approved. Continue to update / educate group on Quality and Infection Metrics. Responsible Party / Due Date / Completion Date: CEO, CCO, DQM (DOQ), the due date or completion date was not documented. QC (Quality Council) Action Taken: Accepted as Presented. Safety Management Plan Summary: January: Major roof leaks. February: More roof leaks. Courtyard flooding. March: More roof leaks ...Findings / Analysis: Recommend replace the roof ...Responsible Party: CCC. QC Action: Accepted as presented.

On 7/18/2023, Quarter 2 Summary indicated the following. Findings / Analysis: Concerns over room repairs. Recommendations, Actions & Follow-up: CCC continue to focus on patch repair and roof project approved ... Responsible Party / Due Date / Completion Date: CEO, CCO, DQM (DOQ), the due date or completion date was not documented. QC (Quality Council) Action Taken: Accepted as Presented. Safety Management Plan Summary: April: Still major roof leaf leaks ...Findings / Analysis: no documentation addressing roof leaks. Recommendations, Actions & Follow-up: no documentation addressing roof leaks. Responsible Party / Due date / Completion: CCC ... no documentation regarding due date or completion dates. QC Actions taken: Accepted as presented.

A review of the facility ' s "Services Agreement", between the facility and the contracted construction company (CCC), dated 2/17/2020, indicated an employee of the CCC shall participate in the environment of Care Committee for each location and shall assist the facility with The Joint Commission and Medicare Conditions of Participation for Physical Environment ...Building Structure and Landscape Maintenance Services: Develop plans and budgets in collaboration with the hospital for the repair and maintenance of building structures (brick exteriors, roofs, doors, walls, etc.), roadways, parking lots, decks, and landscape.

Based on observation, interview, and record review, the facility failed to take actions aimed at ensuring staff, visitor, and patient safety when a mold (a type of fungus that develops on organic matter that is either damp or rotting) -like substance was observed behind a ceiling tile in the Radiology Office, and adjacent rooms and and failed to take actions aimed at fixing the root of cause of water intrusion (unwanted movement of water or vapor into a building. This can cause damage to the building's structure and material) and development of the mold-like substance.

This deficient practice had the potential for mold exposure to staff, patients, and visitors, compromising their safety.

Findings:

During an observation on 8/15/2023 beginning at 9:34 a.m., the following was observed in several areas of the facility. The Radiology Office door was closed. Radiology Technician (RADT) 1 sat in front of a computer inside the Radiology Room. The survey team observed evidence of substance accumulations of black discolorations and white fuzz, that appeared to be mold-like substances and a musty smell in the Radiology Office, in the far-right corner of the room, behind the ceiling tile. Black discolorations and water damage (cracking paint, soft drywall, musty smell) were also observed in the adjacent boiler room (wall and floor), adjacent storage room (dark room, used to storage ultrasound machine [not in use]) and the basement [southeast room used to store personnel files and payroll documents]). At 3:35 p.m., the team also observed evidence of water damage (brown stains) on ceiling tiles, that would support the mold growth to three Patient rooms for Patient 16, 17, 21, 22, 23, and 24.

During an interview on 8/15/2023 at 9:54 a.m., the Lead Engineer (LE) stated that on 8/9/2023, the facility became aware of the stains on the ceiling tiles, black discolorations and white "Spider-like nest" surrounding the pipe on the ceiling of the back of the Radiology Office, and black discolorations and water damage to the adjacent storage room, boiler room and basement. The LE stated the facility replaced two ceiling tiles and added that since 8/9/2023 there has been no action to remediate the possibility of mold in ceiling of the Radiology Office. LE stated that roof repair had been delayed and could not give a reason for the delay.

During an interview on 8/15/2023 at 3:04 p.m., the Director of Quality (DOQ) stated the facility became aware of mold-like substances and water damage in the Radiology Office, and adjacent areas (storage, boiler, and basement) during an inspection by the Department (Public Health) on 8/9/2023. The DOQ stated the facility was waiting for the Department ' s findings to initiate any corrective actions to the specific areas identified in the report. The DOQ stated the facility did not conduct any inspections to identify any other affected areas in the hospital, including patient rooms.

During an interview on 8/16/2023 at 8:20 am, the Director of Quality (DOQ) stated she had observed water intrusion from rainstorms since late 2022 through early 2023. The DOQ verified the roof had not been replaced and could not give a reason for the delay. The DOQ verified limited air quality testing was performed on some areas and added that patient rooms were not tested/inspected for potential presence of mold.

During an interview on 8/16/2023 at 9:33 am, with the Infection Preventionist (IP), the IP stated she has observed water leaks from ceilings of the hospital for the past four (4) years. IP also said those issues were brought to the supervisor ' s attention but there was no follow up. IP also noted that she had taken pictures of rain damage to ceilings for the last 3 years and notified management. IP stated if mold was present in non-patient care areas, managers should place work orders to test areas of concern. IP also verified mold-like substance was observed on 8/9/2023 in the radiology room above the ceiling tile. IP stated air quality testing conducted on 8/9/2023 did not include the radiology room or for the mold-like substance found behind the radiology room ceiling tile but should have been tested. IP agreed that moisture or rain was the perfect medium for growing mold; she continued to say that mold could become air-borne and spread to other areas of the hospital, including patient care areas. IP validated that there was no testing done to patient rooms to verify spread of mold spores to patient rooms. IP stated it would be her practice to do a walk-through of potential rooms affected by mold but there has not been any walk-through as of now. IP stated patients at the hospital were immunocompromised and nearly all suffered from respiratory issues; some symptoms of contact with mold would be masked by symptoms already exhibited by these patients.

During an interview, on 8/18/2023 at 2:34 p.m., with the Chief of Staff (COS), the COS stated the facility analyzed the mold-like substance, however, did not conduct a root cause analysis (RCA, the process of discovering the root cause of a problem to identify appropriate solutions) to determine the cause of the mold-like substance found in Radiology Office on 8/9/2023.

Per report titled "Limited Indoor Air Quality Assessment", inspection date of 3/30/2023, eight organisms resulted on 4/10/2023 report, the Radiology Office, Radiology's Directors office, corridor near the radiology office and near the main lobby and outside the building. There was no evidence of testing in the patient rooms.

Per report titled "Limited Indoor Air Quality Assessment", inspection date 8/9/2023 and result date of 8/11/1023, indicated only limited testing was conducted to the Pharmacy storage room, main corridor near the Entrance to room 154 and front parking lot. There was no evidence of testing in radiology office, boiler room, or radiology dark room, or patient rooms.

A review of a report titled, "2022 Leadership Committee Dashboard", indicated the following:

Date (not visible on document), Quarter 4 Summary, indicated the following. Safety Management Plan Summary: December: Work to mitigate water intrusions. Recommendations, Actions & Follow-up: Continue making repairs to roof until the roof gets replaced. Responsible Party / Due date / Completion Date: Plan Operations and Director of Quality Management (DQM or DOQ), the due date or completion date was not documented.

A review of a report titled, "2023 Leadership Committee Dashboard", indicated the following:

On 4/18/2023, Quarter 1 Summary, indicated the following. Findings / Analysis: Concern over EOC (Environment of Care) leaks related to heavy rain ...Recommendations, Actions & Follow-up: Contracted Construction Company (CCC) continue to focus on patch repair and roof project approved. Continue to update / educate group on Quality and Infection Metrics. Responsible Party / Due Date / Completion Date: CEO, CCO, DQM (DOQ), the due date or completion date was not documented. QC (Quality Council) Action Taken: Accepted as Presented. Safety Management Plan Summary: January: Major roof leaks. February: More roof leaks. Courtyard flooding. March: More roof leaks ...Findings / Analysis: Recommend replace the roof ...Responsible Party: CCC. QC Action: Accepted as presented.

On 7/18/2023, Quarter 2 Summary indicated the following. Findings / Analysis: Concerns over room repairs. Recommendations, Actions & Follow-up: CCC continue to focus on patch repair and roof project approved ... Responsible Party / Due Date / Completion Date: CEO, CCO, DQM (DOQ), the due date or completion date was not documented. QC (Quality Council) Action Taken: Accepted as Presented. Safety Management Plan Summary: April: Still major roof leaf leaks ...Findings / Analysis: no documentation addressing roof leaks. Recommendations, Actions & Follow-up: no documentation addressing roof leaks. Responsible Party / Due date / Completion: CCC ... no documentation regarding due date or completion dates. QC Actions taken: Accepted as presented.

A review of a report titled, "Quality Council Dashboard", dated 7/20/2023, indicated the following: Leadership Committee: Contracted Construction Company (CCC) continues patching and repairing areas with leaks. Roof Project has been approved. QC Recommendations: None documented.

Based on observation, interview, and record review the Governing Body failed to provide adequate resources to ensure the cause of water intrusions (unwanted movement of water or vapor into a building. This can cause damage to the building's structure and material) and the development of a mold (a type of fungus that develops on organic matter that is either damp or rotting) -like substance in areas of the hospital were remedied to reduce potential safety risk for patients, staff, and visitors.

This deficient practice had the potential for mold exposure to staff, patients, and visitors, compromising their safety.

Findings:

During an observation on 8/15/2023 beginning at 9:34 a.m., the following was observed in several areas of the facility. The Radiology Office door was closed. Radiology Technician (RADT) 1 sat in front of a computer inside the Radiology Room. The survey team observed evidence of substance accumulations of black discolorations and white fuzz, that appeared to be mold-like substances and a musty smell in the Radiology Office, in the far-right corner of the room, behind the ceiling tile. Black discolorations and water damage (cracking paint, soft drywall, musty smell) were also observed in the adjacent boiler room (wall and floor), adjacent storage room (dark room, used to storage ultrasound machine [not in use]) and the basement [southeast room used to store personnel files and payroll documents]). At 3:35 p.m., the team also observed evidence of water damage (brown stains) on ceiling tiles, that would support the mold growth to three Patient rooms for Patient 16, 17, 21, 22, 23, and 24.

During an interview on 8/15/2023 at 9:54 a.m., the Lead Engineer (LE) stated that on 8/9/2023, the facility became aware of the stains on the ceiling tiles, black discolorations and white "Spider-like nest" surrounding the pipe on the ceiling of the back of the Radiology Office, and black discolorations and water damage to the adjacent storage room, boiler room and basement. The LE stated the facility replaced two ceiling tiles and added that since 8/9/2023 there has been no action to remediate the possibility of mold in ceiling of the Radiology Office. LE stated that roof repair had been delayed and could not give a reason for the delay.

During an interview on 8/15/2023 at 3:04 p.m., the Director of Quality (DOQ) stated the facility became aware of mold-like substances and water damage in the Radiology Office, and adjacent areas (storage, boiler, and basement) during an inspection by the Department (Public Health) on 8/9/2023. The DOQ stated the facility was waiting for the Department ' s findings to initiate any corrective actions to the specific areas identified in the report. The DOQ stated the facility did not conduct any inspections to identify any other affected areas in the hospital, including patient rooms.

During an interview on 8/16/2023 at 8:20 am, the Director of Quality (DOQ) stated she had observed water intrusion from rainstorms since late 2022 through early 2023. The DOQ verified the roof had not been replaced and could not give a reason for the delay. The DOQ verified limited air quality testing was performed on some areas and added that patient rooms were not tested/inspected for potential presence of mold.

During an interview on 8/16/2023 at 9:33 am, with the Infection Preventionist (IP), the IP stated she has observed water leaks from ceilings of the hospital for the past four (4) years. IP also said those issues were brought to the supervisor ' s attention but there was no follow up. IP also noted that she had taken pictures of rain damage to ceilings for the last 3 years and notified management. IP stated if mold was present in non-patient care areas, managers should place work orders to test areas of concern. IP also verified mold-like substance was observed on 8/9/2023 in the radiology room above the ceiling tile. IP stated air quality testing conducted on 8/9/2023 did not include the radiology room or for the mold-like substance found behind the radiology room ceiling tile but should have been tested. IP agreed that moisture or rain was the perfect medium for growing mold; she continued to say that mold could become air-borne and spread to other areas of the hospital, including patient care areas. IP validated that there was no testing done to patient rooms to verify spread of mold spores to patient rooms. IP stated it would be her practice to do a walk-through of potential rooms affected by mold but there has not been any walk-through as of now. IP stated patients at the hospital were immunocompromised and nearly all suffered from respiratory issues; some symptoms of contact with mold would be masked by symptoms already exhibited by these patients.

During an interview, on 8/18/2023 at 2:34 p.m., with the Chief Operations Officer (COO), the COO stated the project to repair had been "ongoing for a while", and the facility had only been patching the roof in the areas where water leakage was identified.

During an interview, on 8/18/2023 at 2:34 p.m., with the Chief of Staff (COS), the COS stated the facility analyzed the mold-like substance, however, did not conduct a root cause analysis (RCA, the process of discovering the root cause of a problem to identify appropriate solutions) to determine the cause of the mold-like substance found in Radiology Office on 8/9/2023. The COS stated the facility has had problems with water leakage during rainstorms since 2020. The COS stated the facility was patching areas of the roof as needed. The COS stated the roof repair did not happen fast enough and there were no excuses, however, there were delays related to the complexity of the roof and necessary equipment.

Per report titled "Limited Indoor Air Quality Assessment", inspection date of 3/30/2023, eight organisms resulted on 4/10/2023 report, the Radiology Office, Radiology's Directors office, corridor near the radiology office and near the main lobby and outside the building. There was no evidence of testing in the patient rooms.

Per report titled "Limited Indoor Air Quality Assessment", inspection date 8/9/2023 and result date of 8/11/1023, indicated only limited testing was conducted to the Pharmacy storage room, main corridor near the Entrance to room 154 and front parking lot. There was no evidence of testing in radiology office, boiler room, or radiology dark room, or patient rooms.

A review of a report titled, "Governing Board Report", dated 6/6/2022, indicated "Old Business" topics included Roof repair. No other details were documented.

A review a report titled, "Old business Tracking - Q (Quarter) 2, Governing Board Meeting", dated 9/27/2022, indicated GB (Governing Board) recommendations for follow up included roof repair. Date to be completed: ongoing. Responsible party: Administration / Contracted construction service. Actions taken: Continue weekly update call with Director of Facilities Manager. Date Completed: Waiting for Certification.

A review a report titled, "Old business Tracking - Q (Quarter) 3, Governing Board Meeting", dated 12/13/2022, indicated GB (Governing Board) recommendations for follow up included roof repair. Date to be completed: ongoing. Responsible party: Administration / Contracted construction service. Actions taken: Continue weekly update call with Director of Facilities Manager. Date Completed: Waiting for Certification.

Based on observation, interview, and records review, the facility failed to appropriate mitigation and corrective actions to safeguard staff, 57 of 57 Patients (1 - 57), and visitors in response to mold (a type of fungus that develops on organic matter that is either damp or rotting) -like substances found in the facility's radiology office (Room 136), the radiology storage area (Room 116), the boiler room, and in the basement areas.

This deficient practice had the potential to negatively affect the patients, staffs and visitors' health and safety.

On 8/16/2023 at 4:34 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Director of Quality (DOQ), Director of Nursing (DON), Clinical Operations Officer (COO), Senior Facility Manager (SFM), and via telephone conference, Market Chief Executive Officer (MCEO), Regional Nursing Officer (RNO), Vice President of Quality & Accreditation (VPQA), Vice President of Clinical Services (VPCS), Director of Engineering Support (DES), Survey Readiness Team Member (SRTM), and the Regional Facility Manager (RFM). The facility failed to adequately prevent, control, mitigate, and or abate substances that appeared to be mold in the Radiology Office, in the adjacent storage room and boiler room, and in the basement. This deficient practice had the potential for serious harm when the facility did not conduct inspection to patient rooms after acknowledging there was a potential for transmission of mold spores to all immunocompromised (a weakened immune system) patients. The Department also received information from an employee whose urine test results on 6/12/2023 and 6/24/2023 showed positive presence for mold exposure.

On 8/18/2023 at 5:07 p.m., the IJ was removed in the presence of DOQ, COO, DON, SFM, and the RFM after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed on-site through observations, interview, and record review. The acceptable IJ Removal Plan included: the affected room will remain sealed off and clean up occurs, inspection and air sampling test of all patient rooms, and walk through to building to identify additional areas for water intrusion (unwanted movement of water or vapor into a building. This can cause damage to the building's structure and material) and air sampling test. The Plan also included staff education to remind staff to report water intrusion, wet spots, condensation on walls or ceilings, and discoloration or stains to the Nursing Supervisor.

Findings:

During an interview on 08/15/2023 at 9:34 a.m. with Lead Engineer (LE), the LE stated, "No" when asked if the facility took any actions to remedy, mitigate, abate, limit exposure to the mold like substances observed on 08/09/2023 with evaluator A and located in the radiology office (Room 136), the radiology storage area (next room from the radiology office) and the boiler room (also next door to the radiology room office).

During an interview on 08/15/2023 at 9:34 a.m., the Director of Quality Management (DOQ) and Chief Clinical Officer / Director of Nursing (DON) stated that the facility informed evaluator A, verbally and in writing, on 08/03/2023 that the facility would implement a major roofing project because of multiple water leaks from rainwater; the potential mold growth; and to protect the facility's electrical system, and that they would start the major roofing project on 08/07/2023, as their immediate actions. However, the facility did not initiate the major roof project repair. The DOQ and DON stated they did not know the reason the project was not yet started.

During an interview on 08/15/2023 at 9:44 a.m., the LE stated that although mold like substances were observed in the radiology office (Room 136) on 08/09/2023, the mold like substances were not abated; the office room was not closed off; and it was still in use by two to three staff each day.

During an observation on 08/15/2023 9:45 a.m., the evaluators noted that a staff person (Radiology Technician) was working in the radiology office (Room 136).

During an interview on 08/15/2023 at 9:45 a.m. with the Radiology Technician (RADT 1) in the radiology office (Room 136), he stated that he continually worked in radiology office (room 136) during his work shifts.

During an observation on 08/15/2023 at 9:50 a.m., the evaluator A observed that the ceiling space above the dropped ceiling tiles in the radiology office (Room 136) had accumulations of mold like substances. The evaluator noted that the ceiling had an opened penetrations into the attic space, measuring 9 inches by 1/4 to over 1 inch wide around the opening's circumference. The evaluator further noted that white/light gray colored mold like substance with web like textures was accumulated on the ceiling. The white/light gray colored mold like substance circled the opened penetration in the ceiling by a two-foot diameter. The evaluator also noted that the ceiling around the opened penetration had accumulations of black colored mold like substances, that extended across the ceiling to more than four feet. Furthermore, the evaluator noted that there were multiple opened penetrations in the office's drop ceiling tiles.

During an interview on 08/15/2023 at 9:54 a.m., the LE stated that the white/light gray colored mold like substance circled the opened penetration in the ceiling in the radiology office (Room 136) appeared to have a web stringy texture. The LE stated that he also observed the accumulations of the black colored mold like substances on the ceiling, and that he did not know what it was.

During a concurrent observation and interview on 8/15/2023 at 10:13 a.m. with the LE in the "dark room" (the back storage room in the storage room 116), the LE stated that he observed the water damaged walls; the bubbling and opened blisters of paint and plasters; and that he also observed the accumulations of the black colored, mold like substances in the opened blisters of plasters, but he did not know what it was.

During a concurrent observation and interview on 08/15/2023 at 10:15 a.m. with the Registered Quality Analyst (QA) in the "dark room", the QA stated that the accumulations of the black colored substances in the opened blisters of plasters looked like mold.

During an observation on 08/15/2023 at 10:26 a.m., the evaluator A observed that the facility had a boiler room that was also adjacent to radiology office (room 136) and the radiology storage room/dark room 116. The evaluator also noted that the boiler room had accumulations of mold like materials on the southwest facing walls and floor, which measured 6 feet by 2-1/2 feet on the floor and 6 to 7 feet by 5 feet on the walls. The evaluator noted that the floor had accumulations of a black color substance; that the floor area was wet with fluids and sludge; and that water was seeping downs from a back flow prevention device downwards towards the floor. The evaluator noted that the walls had black streaks of mold like substances. The evaluator further noted that the walls had several opened penetrations and had water damages with wall plaster deteriorating and tearing apart from the walls.

During a concurrent observation and interview on 08/15/2023 at 10:30 a.m., the LE stated that the water leaking from the back flow prevention device in the boiler room, adjacent to Room 136, had been pooling on the floors that damaged the walls. The LE stated floors had a blacken colors in the area with the pooling of water and that the wall damages were due to the water leakage.

During an observation on 08/15/2023 at 10:36 a.m., the evaluator A observed that the facility had a boiler room on the northside of the facility. The evaluator noted that the boiler room ceiling had an opened penetration, measuring 4 inches by 3 inches, and that the opened penetration was positioned above and near the area with the observation of water pooling and the accumulations of mold like substances.

During a concurrent observation and interview on 08/15/2023 at 10:37 a.m., the QA stated that the ceiling in the boiler room, located on the northside of the facility, had an opened penetration. At 3:35 p.m., the team also observed evidence of water damage (brown stains) on ceiling tiles, that would support the mold growth to three Patient rooms for Patients 16, 17, 21, 22, 23, and 24.

During a concurrent observation and interview on 8/15/2023 at 11:16 a.m. with the LE, the evaluator A observed that the facility had a basement with rooms on the east side of the basement. In the room adjoining the far east located room, the evaluator observed that the room's west facing wall had accumulations of black colored, mold like substances, across wall space that measured 8 feet by 14 inches. The LE stated that he observed the accumulations of black colored mold like substances located on the west most facing wall. The LE also stated that the accumulation could be mold from water damage.

During an interview on 8/15/2023 at 2:58 p.m. and on 8/16/2023 at 8:21 a.m., the DOQ stated that on 08/09/2023, the facility representatives acknowledged with evaluator A that the facility had evidence of mold like substances located in the radiology office (Room 136), boiler room and the radiology storage room/dark room 116, which these rooms were all adjacently to one another. The DOQ further stated that the facility administrative staff decided not to take mitigative and or corrective actions. The DOQ also said the facility did not test the areas to identify the mold like substances, and that the facility did not restrict or eliminate access to the areas identified with the mold like substances. Furthermore, the DOQ stated that she started working for the facility in July 2022, and that she first became aware that rainwater leaked into the facility at multiple locations with the start of the rain season during the fall of 2022.

During an interview, on 8/15/2023 at 3:04 p.m., the DOQ stated the facility became aware of mold-like substances and water damage in the Radiology Office, and adjacent areas (storage, boiler, and basement) during an inspection by the Department (Public Health) on 8/9/2023. The DOQ stated the facility was waiting for the Department's findings to initiate any corrective actions to the specific areas identified in the report. The DOQ stated the facility did not conduct any inspections to identify any other affected areas in the hospital, including patient rooms.

During an interview, on 8/16/2023 at 8:20 am, the DOQ stated she had observed water intrusion from rainstorms since late 2022 through early 2023. The DOQ verified the roof had not been replaced and could not give a reason for the delay. The DOQ verified limited air quality testing was performed on some rooms.

During an interview on 08/16/2023 at 9:32 a.m. with the Infection Preventionist/ Director of Employees Health (IP), she stated she started working for the facility in 2020, and that the facility had an ongoing problem with rainwater leaking into the facility through the roof and ceiling that presented safety hazards issues. The IP stated she was included in the meeting with evaluator A on 08/09/2023 when the presence of mold like substances in the facility was discussed; and she stated, "No" when asked if there were any protective and corrective actions taken for evidence of mold like substances located in the radiology office (Room 136), boiler room and the radiology storage room/dark room 116.

The IP said that the staff continued to work in the radiology office (Room 136) and that since the evaluator meeting with her and the administrative staff on 08/09/2023, she did not know if the room was ever closed off and that she did not know if the room was tested for mold. The IP stated that if mold or mold like substances were discovered in staff areas and or patients areas, then that affected area should be closed off, not used and that she would report the problem to administrative staff. The IP further stated the facility did not have policy and procedures that addressed procedures to take if mold or mold like substances were discovered in the facility.

The IP stated that the facility's policies and procedures, such as the Airborne Transmissible Disease Standard, dated 09/2010, and the Tuberculosis control plan, dated 12/1999, did not address procedures to take in case of the presence of mold and or mold like substances. The IP stated that the radiology office (Room 136) shared a corridor (center way) with ten patients' bedrooms (patients rooms 30, 31, 32, 33, 34, 35, 36, 37, 38 and 40, Patients 10 - 21) and the radiology office (room 136) was also closely located to the intensive care unit by way of a cross corridor. The IP stated that there was a potential of cross contamination of the mold/ mold like substance to the close by patients care areas.

The IP further stated that the facility specialized in patient population with respiratory issues, and that the patients' population would already demonstrate respiratory distresses and that mold exposures could cause signs and symptoms already demonstrated by the patient population, and this is the reason the facility did not test the patient population for mold exposure. The IP further stated the facility did not take other measures, such as a statically reliable epidemiology testing study of patients to determine exposures and or infections from mold.

During a review of the facility's Airborne Transmissible Disease Standard, dated 09/2010 and 05/2021, the document indicated, the scope of the policy was that healthcare workers with contact with patients may be infected with any aerosol transmissible diseases listed in the policy's appendix A.

During a review of the facility's Safety Management Plan, dated 05/2015 and 06/2022, the document indicated, the facility was to implement and monitor programs to maintain a safe environment for patients, staff and visitors to the facility; the safety officer was to implement actions to mitigate environmental risk by coordinating risk reduction activities, monitoring and reporting safety compliance data and disseminate summaries of actions and results; and the facility was to ensure that risk assessments were completed regularly to assess and respond to risks in the facility's environment, including examining risks and their potential consequences, determining mitigating factors and whether safeguards are needed to prevent or lessen identified risks. Furthermore, the policy and procedure stated that the facility was to take action to minimize or eliminate safety risks in the physical environment.

During a review of the report titled "Limited Indoor Air Quality Assessment," with inspection date of 3/30/2023, eight organisms resulted on 4/10/2023 report, for the Radiology Office, Radiology's Directors office, corridor near the radiology office and near the main lobby and outside the building. There was no evidence of testing in the patient rooms.

A review of the report titled, "Limited Indoor Air Quality Assessment", with inspection date of 8/9/2023 and result date of 8/11/1023, indicated only limited testing was conducted to the Pharmacy storage room, main corridor near the Entrance to room 154 and front parking lot. There was no evidence of testing in radiology office, boiler room, or radiology dark room, or patient rooms.

Based on observation and interview, the facility failed to ensure that doors to the clean linen room and storage room located on the west side of the facility were not obstructed from closing.

In the event of fire and /or smoke emergency, doors that do not resist the passage of smoke establish conditions conducive to the rapid spread of fire, smoke, and heat to the rest of the facility.

This deficient practice has the potential for the inability for the rapid closure of doors without any impediment for the containment of smoke and/or fire in the event of a fire emergency.

Findings:

1. During a complaint validation survey observations on 08/15/2023 10:49 a.m., the evaluator observed that the facility had a clean linen room on the west side of the basement floor. The evaluator also noted that a large linen cart was used to hold the clean linen room's door in the opened position, preventing the door from closing.

During a complaint validation survey observations on 08/15/2023 10:50 a.m., the evaluator observed that the facility had a storage room on the west side of the basement floor. The evaluator also noted that equipment was used to hold the storage room's door in the opened position, preventing the door from closing.

During a complaint validation survey interview, during the observations on 08/15/2023 at 10:50 a.m., the lead engineer stated that the clean linen room and the storage room were not in current use and that the staff should not have blocked the doors in the opened position, in which was a fire hazard.

2. During a complaint validation survey observations on 08/15/2023 10:56 a.m., the evaluator observed that the facility had a staircase between the ground level and the basement floors, and that the stairway had a fire door at the basement level.

The evaluator also noted that a stand was used to hold the stairway's door in the opened position, preventing the door from closing.

During a complaint validation survey interview, during the observations on 08/15/2023 at 10:56 a.m., the lead engineer stated that the staff blocked the door in the opened position and left. The lead staff stated that the staff should not blocked the door in the opened position, in which was a fire hazard.

The deficiencies were brought to the attention of the [facility's representatives] during the exit conference on 08/18/2023.

Based on observation, interview, and record review, the facility failed to maintain:
1) Hot water plumbed to one out of one sampled sinks (decontamination sink - a sink used to wash off biological materials such a flesh, blood and other materials prior to sterilization) in the Decontamination Room (room where surgical tools are cleaned).
2) Safe, hot water temperature by supplying hot water measuring higher than 120 degrees Fahrenheit (F, a unit of measuring temperature) at sinks in four out of four sampled patient rooms (Room 10, Room 12, Room 26, and Room 34).

This deficient practice has the potential to result in:
1) Ineffective removal of contaminants (a biological, chemical, physical or radiological substance that becomes harmful for humans or living organisms) including blood, tissue, and other hazardous materials from surgical instruments (reusable metal tools used during surgical procedures) in the decontamination sink.
2) Severe burns from to patients and visitors using the bathroom sinks.

Findings:

1) During a concurrent observation and interview, on 8/17/2023, at 10:18 a.m., with the Director of Nursing (DON), in the Decontamination Room, when the hot water handle to the decontamination sink was turned on, it was observed that no water came out of the faucet. The water temperature coming from the faucet when the cold water handle was turned on measured at 71.5 degrees F. The DON stated that she was not aware that the decontamination sink lacked hot water and that the sink should be supplied with hot water.

2) During a concurrent observation and interview on 8/17/2023, between 10:49 a.m. and 11:20 a.m., with the SFM and DoQ, the following water temperatures were measured in the patient bathrooms:
Room 10 - 139 degrees F
Room 12 - 136 degrees F
Room 26 - 135.6 degrees F
Room 34 - 141 degrees F
The DoQ stated that water measuring at 140 degrees F in the patient rooms. The SFM stated that the maximum temperature that water should reach in patient rooms is 120 degrees F.

During an interview on 8/17/2023, at 11:00 a.m., with Patient G and Nursing Supervisor (NS), in Room 10, Patient A stated that he uses the bathroom by himself and uses the sink to wash his hands. The NS verified that Patient G is ambulatory (able to walk around on their own).

During a review of the facility's policy titled, "Utilities Management Plan", dated 6/2021, the policy indicated, "The hospital designs and install utility systems that meet patient care and operational needs."

During a review of the facility's policy titled, "Water Management Program/Plan for Legionella and Other Waterborne Pathogens", dated 6/2022, the policy indicated, "Maximize Legionella control through temperature by maintaining hot water temperature to the highest temperature allowed by local regulation or to the following control limits: Hot water at the tap 122 F".

Based on observation, interview, and record review, the facility failed to maintain:

1) The self-closing door mechanism (the equipment on the top of the door that closes the door without assistance) on the OR door.
2) The vent grille (metal cover to the ventilation outlet in the ceiling) in a clean manner.
3) Two Heating, Ventilation, and Air Conditioning (HVAC) systems in good operational condition.
4) Two light fixtures free from evidence of leaking and damage.
5) The sewer line in the southeast area of the basement in good operating condition.
6) The cement foundation beneath one of two hot water boilers in good repair.
7) The building free from water damage in the following areas:
- One out of one Operating Rooms (OR 2)
- Four out of 13 patient rooms (Room 12, Room 14, Room 22, and Room 23)
- The main central room of the Intensive Care Unit (ICU)
- The southeast section of the basement
- The Radiology Office (Room 136)
- The Radiology Storage Room (Room 116)
- The hot water boiler room.

These deficient practices had the potential to result in:
1) The compromise of the sterility of the surgical environment.
2) Dust and debris blowing into the patient rooms.
3) Water damage from the pooling condensation (water dripping from the HVAC units due to the difference in temperature) on the roof.
4) Short circuits, shocks, and possible fires.
5) The discharge of contaminated sewer water inside of the facility.
6) Unstable foundation beneath the hot water boiler.
7) Deteriorating ceiling, walls, and paint throughout the facility.

Findings:


1) During a concurrent observation and interview on 7/18/2023, at 10:14 a.m., with the FSM, in OR 2, the door to the OR was observed to be partially open. The FSM stated that since the OR door was outfitted with the self-closing door mechanism, that the door should shut completely.

2) During an observation on 8/17/2023, at 11:20 a.m., in Room 26, an accumulation of dust and debris was observed on the vent grille in the entranceway to the room.

3) During a concurrent observation and interview on 8/17/2023, at 11:39 a.m., with the FSM, on the roof, pooled water measuring eight feet across beneath the HVAC ventilation system was observed by Air Conditioning Unit (AC) #9 and AC #12. An active water drip from AC #2 was observed to be pooling beneath the unit. The FSM stated that the pooled water was from the HVAC units and that the water was accumulated because the part of the system that contains the condensation was overfilled.

4) During an observation on 8/15/2023, at 11:28 a.m., in the corridor between the Pharmacy Office and Storage Room 129, a light fixture in the ceiling without a light cover (plastic cover over the light bulbs) was observed with brown-reddish colored rusted material at one corner of the lamp's metal constructed unit.

During a concurrent observation and interview on 8/15/2023, at 11:42 a.m., with the LE, in the corridor in the west wing outside of the Pharmacy Office and Storage Room, a water leak was observed to be leaking on a conduit line (a tube used to protect and route electrical wiring in a building or structure) in the ceiling space. The conduit line and the clamp holding the line to the ceiling was observed to have evidence of brown-reddish colored rusted material on their surfaces. The LE stated that water was still leaking from the roof; because the facility had leaking piped water line on the roof, and the roof was in disrepair which allowed the water to enter into the facility.

5) During a concurrent observation and interview on 8/15/2023, at 11:07 a.m., with the Registered Quality Analyst (RQA) and the LE, on the east side of the basement, a 3 inch diameter sewage pipe transverse (situated or extending across something) into a wall on the east side of the room was observed to have an accumulation of brown and dark brown sludgy textured substance streaking down from the contact point between the east facing wall and the pipe. It was noted that the substance had a pungent, musty, and wet smell. The RQA stated that the accumulation of brown and dark brown sludgy textured substance was evidence of the erosion (wearing away) of the sewage pipe and that the substance smelled like sewage. The LE stated that the sewage drainpipe originated from the kitchen and that the area had an odor that was not pleasant.

During a concurrent observation and interview on 8/15/2023, at 11:12 a.m., with the LE, in the room on the east side of the basement, a sewage drainpipe lines that transverse the room was observed to have two pipe coupling clamps (clamping devices use to connect separate pipes to one another); with evidence of leakage and deterioration. The bottom edges of the clamps were observed to have an accumulation of black and white colored calcification-like material that was sprouting from the bottom rubber portions of the clamps. The LE stated that the black and white materials were visible on the clamps.

6) During a concurrent observation and interview on 8/15/2023, at 10:27 a.m., with the Lead Engineer (LE), in the Boiler Room, the concrete base beneath the boiler was observed to be broken and split apart on three out of the four sides of the foundational concrete slab. The LE stated that foundation beneath the boiler was damaged.

7) During an observation on 08/15/2023 10:02 a.m., in the Radiology Storage Room's back Dark Room, the room's walls were observed to have water damage, consisting of bubbling, and cracked paint and plaster measuring at 6 feet across by 1 to 4 feet in height on the north facing wall; and water damage on the east facing wall that measured at 2½ feet across and 2 feet in height. Several opened blisters (small open pockets of wall material) of plaster on the wall of the Dark Room were observed to have an accumulation of black substance on the surface.

During an observation and interview on 8/15/2023, at 10:58 a.m., with the LE, in the corridor between the east and west ends of the basement, the ceiling of the corridor was observed to have damaged paint and missing portions of the ceiling material measuring at 10 feet by 4 feet. The LE stated that the facility's boilers were located on the first floor immediately about the basement corridor and that the water leakage from the boiler area had caused the ceiling to deteriorate.

During a concurrent observation and interview on 8/17/2023, at 10:09 a.m., with the Senior Facilities Manager (SFM), in OR 2, the ceiling of the OR was observed to have cracking and sagging paint next to the light fixture in the middle of the ceiling. The sagging paint on the ceiling was observed to have grey spots forming. The SFM stated that he did not know what the grey spots on the ceiling were and that the cracking paint and spotting appeared to have been from a leak. The SFM stated that the cracking ceiling should be repaired.

During an observation on 8/17/2023, between 11:06 a.m. and 11:17 a.m., the following was observed:
Room 12 - Cracking ceiling next to the wall over the clock.
Room 14 - Yellowing ceiling next to the wall by the bed curtain.
Room 22 - Bubbling paint on ceiling around the bed curtain track.

During a concurrent observation and interview, on 8/17/2023, at 11:19 a.m., with the Director of Quality (DoQ), in Room 23, a softened wall with peeling paint and discoloration was observed next to the light on the wall. Peeling and bubbling paint was observed around the sprinkler (piece of metal equipment fixed into the ceiling for dispensing water during a fire) in the middle of the ceiling. The DoQ verified that the wall was soft by touching it and stating that the wall felt soft to the touch.

During an observation on 8/17/2023, at 11:30 a.m., in the Central Room of the ICU (room where the nurse's station is location and serves as the entrance to all the individual ICU Patient Rooms), a ceiling tile in front of the entrance to ICU Room 5 was observed to be yellowing and discolored.

During a review of the record titled, "Utilities Management Plan", dated 06/2021, the policy indicated, "Designing, installing, and maintaining ventilation equipment for the control of airborne contaminants". The policy indicated the goal of the facility is to "provide a safe environment for its patients, visitors, and staff by managing, maintaining, testing, and inspecting utility systems to promote a safe, controlled, and comfortable environment."


46739

Based on observation, interview, and record review that facility failed to maintain sensitive areas including the OR, the Decontamination Room, and sterile holding areas with proper temperature, relative humidity (the amount of water vapor present in air) levels and air pressure levels.

This deficient practice had the potential for microbial growth to occur on the sterile instruments and for microbes to spread in sterile areas resulting in increased infections and risk to patients receiving surgical services.

Findings:

During a concurrent observation and interview on 8/17/2023, at 9:47 a.m., with the FSM, the Sterile Storage Room (a temperature and humidity controlled room where sterile surgical instruments are stored), the relative humidity was indicated to be 66.9% per the monitor on the wall by the doorway to the room. The FSM stated that the relative humidity should not exceed 60% for this room.

During an observation and interview on 8/17/2023, at 10:01 a.m., with the FSM and the Nursing Supervisor (NS), in the room between the OR and the Sterile Supply Room, sterile supplies including laryngoscope blades and handles (tools used to assist with putting tubes in the lungs from the mouth for the purposes of putting a patient on a machine that assists with breathing) inside of sterile packaging (packages with special tape indicating that the tools had been sterilized) were observed being held in a space that was not monitored for temperature or humidity. A green laminated sign inside of the room by the door indicated, "Temp Range - 68-75 degrees, Humidity Range = 20%-60%, If area out of range contact Engineering immediately, log and monitor situation, 11/2019". The NS stated that the equipment in the room was considered sterile. The FSM stated that there was no temperature monitoring in this room.

During an observation on 8/17/2023 at 10:09 a.m., a blue laminated sign inside of the room by the door indicating, "Temp Range = 68-75 degrees, Humidity Range = 20%-60%, If area out of range contact Engineering immediately, log and monitor situation, 11/2019" was observed.

During a review of the record titled, "OR Temperature, Air Pressure, and Humidity Log - Sterile Supply" dated 8/2023, the log indicated, "Humidity Range 20-60% and Temperature Range 68-75 degrees F". The log indicated that sterile supply room had the humidity above 60% on the following dates without notes of an action taken to adjust the humidity:
8/1/2023 - Humidity 70%
8/2/2023 - Humidity 65%
8/3/2023 - Humidity 64%
8/4/2023 - Humidity 65% (Action taken for facility to adjust temperature on this date, humidity not documented)
8/5/2023 - Humidity 66%
8/6/2023 - Humidity 65%
8/7/2023 - Humidity 65%
8/8/2023 - Humidity 64%
8/9/2023 - Humidity 67%
8/10/2023 - Humidity 67%
8/11/2023 - Humidity 67%
8/12/2023 - Humidity 68%
8/13/2023 - Humidity 67%
8/14/2023 - Humidity 67% (Action taken for facility to adjust temperature on this date, humidity not documented)

During a review of the record titled, "OR Temperature, Air Pressure, and Humidity Log - OR 2", dated 7/2023, the log indicated, "Humidity Range 20-60% and Temperature Range 68-75 degrees F". The log indicated that OR had the humidity above 60% or a temperature above 75 degrees F on the following dates without notes of an action taken to adjust the humidity or temperature:
7/12/2023 - Temperature 76 degrees F
7/18/2023 - Humidity 67%
7/20/2023 - Humidity 67% (Action taken for facility to adjust temperature on this date, humidity not documented)
7/21/2023 - Humidity 71% (Action taken for facility to adjust temperature on this date, humidity not documented)
7/22/2023 - Humidity 63%
7/23/2023 - Humidity 64% (Action taken for facility to adjust temperature on this date, humidity not documented)
7/25/2023 - Humidity 69% (Action taken for facility to adjust temperature on this date, humidity not documented)
7/26/2023 - Humidity 61% (Action taken for facility to adjust temperature on this date, humidity not documented)
7/27/2023 - Humidity 64% (Action taken for facility to adjust temperature on this date, humidity not documented)
7/28/2023 - Humidity 61%
7/29/2023 - Humidity 64%
7/30/2023 - Humidity 70%
7/31/2023 - Humidity 70%

During a review of the record titled, "OR Temperature, Air Pressure, and Humidity Log - Sterile Supply", dated 7/2023, the log indicated, "Humidity Range 20-60% and Temperature Range 68-75 degrees F". The log indicated that sterile supply room had the humidity above 60% on the following dates without notes of an action taken to adjust the humidity:
7/18/2023 - Humidity 66%
7/19/2023 - Humidity 79% (Action taken for facility to adjust temperature on this date, humidity not documented)
7/20/2023 - Humidity 75% (Action taken for facility to adjust temperature on this date, humidity not documented)
7/21/2023 - Humidity 73% (Action taken for facility to adjust temperature on this date, humidity not documented)
7/22/2023 - Humidity 66%
7/23/2023 - Humidity 70%
7/24/2023 - Humidity 70%
7/25/2023 - Humidity 69%
7/26/2023 - Humidity 66%
7/27/2023 - Humidity 64%
7/28/2023 - Humidity 68%
7/30/2023 - Humidity 63%
7/31/2023 - Humidity 63%

During an interview on 8/18/2023 at 10:10 a.m., with RN 1 and the DON, RN 1 stated that the Sterile Storage Room and OR should be under humidity and temperature control to maintain the sterility of the equipment and to ensure a safe environment. RN 1 stated that the room where the laryngoscopes were held was not monitored for temperature or humidity. RN 1 stated that when the humidity or temperature is outside of the range, the staff in the OR is supposed to contact the Engineering staff to make adjustments and that the Engineering Department had a log of the adjustments made to the temperature and humidity.

During an interview on 8/18/2023, at 4:05 p.m., with the LE, the LE stated that there is no log where Engineering keeps a record of the temperature or humidity adjustments and that Engineering staff will adjust the temperature and humidity but have the expectation that the OR staff will document the changes. The LE stated that he did not recall being notified to adjust the temperature or humidity every day for the month of August.

During a review of the record titled, "Temperature Control of the Operating Room", dated 6/2023, the policy indicated, "Sterile Storage: Maximum 75°F (24 °C)" and "Operating Room: 68° to 75° (20° -24 ° C)" should be maintained in the respective areas.

During a review of the record titled, "Humidity in the Surgical Suite", dated 6/2023, the record indicated, "General architectural standards and regulatory guidelines dictate relative humidity levels to be maintained between 20% and 60% in anesthetizing locations (OR, PACU, Procedure room, and GI Endoscopy Procedure Room) within the hospital" and "Sterile processing clean workrooms maintain a relative humidity maximum level of 60%."

During an observation on 8/17/2023 at 10:33 a.m., in the Decontamination Room, the door to the room was observed to be open while surgical instruments were out drying after the decontamination process.

During an observation on 8/18/2023, at 10:05 a.m., in the Decontamination Room, the door to the room was observed to be open while surgical instruments were out drying after the decontamination process.

During an interview on 8/18/2023 at 10:10 a.m., with RN 1 and the DON, RN 1 stated that the door to the Decontamination Room should be closed all the time to maintain a negative pressure environment in that room. RN 1 stated that the door to the room should especially be closed while there were surgical instruments out in the open.

During a review of the record titled, "Utilities Management Plan", dated 06/2021, the policy indicated, "In areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust), the ventilation system provides appropriate pressure relationships, air-exchange rates, and filtration efficiencies."

Based on observation, interview, and record review, the facility failed to develop and implement policies and procedures related the storage of scrubs (a protective garment designed to be worn by the doctor, nurse, and others in the operating room) used in the operating rooms and clean linen.

This deficient practice had the potential for the spread of infection.

Findings:

During an observation on 8/15/2023 at 10:45 am, in a room in the basement, the following was observed. Several (approximately 3 to 5) blue scrub pants with orange-colored drawstrings were observed on the lowest shelf on a rack. The drawstrings were touching the un-swept floor. Some of the blue scrubs (top and bottoms) were not stored in plastic bags on the rack. Two plastic bags, containing blue scrubs were observed on the floor. Two clean towels were observed on the floor.

During an interview on 8/15/2023 at 10:45 am, with the Quality Analysist (QA), the QA stated the scrubs were used in the operating room and should be stored in plastic bags and should not touch the floor. The QA added that the rack should also be covered.

During an observation on 8/18/2023 at 12:30 p.m., in a room in the basement, the following was observed. Four racks containing clean linen, towels, and hospital gowns were observed uncovered. Some clean towels were observed on the un-swept floor. Clean cleaning cloths were also observed uncovered on racks. Additionally, a linen cart, containing clean linen and hospital gowns, was observed uncovered.

During an interview on 8/18/2023 at 12:30 p.m., the Director of Quality (DON) stated that clean linen and gowns should covered and stored in a clean room.

During an interview, on 8/18/2023 at 10:14 a.m., the operating room registered nurse (RN) 1, RN 1 stated the following. The facility provided scrubs for staff to use during surgeries. The blue scrubs with orange drawstrings are used in the operating room.

During an interview on 8/18/2023 at 2:15 p.m., the Director of Nursing (DON) stated the facility did not have a policy and procedure for the storage of hospital scrubs and clean linen.

Based on observation, interview, and record review, the facility failed to ensure the facility followed infection control policies and procedures.

1. Sterile equipment including laryngoscope (a thin tube with a light, lens, and video camera that doctors use to examine the larynx, or voice box) handles, respiratory therapy equipment, and urinary catheters (flexible tube that drains the bladder and collects urine in a drainage bag) were stored in areas that did not have temperature or humidity monitoring.

2. The door to the decontamination room was left open in the semi-restricted area of the Surgical Suite adjacent to the operating room (OR).

These deficient practices had the potential for the spread of infection.

Findings:

During an observation on 8/17/2023 at 10:30 a.m., in the Surgical Suite, the following was observed. Sterile supplies, including urinary catheters, respiratory therapy equipment, and laryngoscope handles were observed in the unrestricted area. The door to the decontamination (an area equipped with tools used to remove contaminants from used surgical instruments) room was left open. Instruments were observed on the counter in the decontamination room.

During an interview on 8/17/2023 at 11:05 a.m., the Director of Nursing (DON) stated that the un-restricted area was not monitored for temperature and humidity and added that sterile equipment should be stored in an area where the temperature and humidity are monitored to ensure the sterility of the supplies were not compromised. In addition, DON stated that the door to the decontamination room should be closed at all times to avoid cross-contamination.

During an interview on 8/17/2023 at 11:38 a.m., the Surgical Technician (ST) 1 stated the instruments in the decontamination room had been cleaned and were drying on the counter.

During an interview, on 8/18/2023 at 10:44 a.m., with the operating room Registered Nurse (RN) 1, RN 1 stated the door of the decontamination room should be closed to maintain negative pressure to avoid the spread of infection. RN 1 also stated that sterile instruments should be stored in a room where temperature and humidity are monitored to ensure the integrity of the instruments.

During a review of the facility ' s policy and procedure (P&P) titled, "Air Exchange, Air Quality and Pressure Differential in the Surgical Suite", dated 6/2022, the P&P indicated Negative airflow areas include soiled decontamination rooms ...

During a review of the facility ' s policy and procedure (P&P) titled, "Humidity in Surgical Suite", dated 6/2023, indicated this policy establishes guidance to perioperative staff regarding monitoring relative humidity control in the surgical suite. Low humidity levels increase the risk of electrostatic charges, posing a fire hazard risk. High humidity increases the risk of microbial growth. Therefore, humidity monitoring and recording will include all active and inactive operating/rooms and other designated areas requiring humidity monitoring in the surgical suite, regardless of how the space is utilized (for surgeries or other purposes). The P&P indicated the humidity will be recorded by a designee of the surgical department as determined by the facility.

During a review of the facility ' s policy and procedure (P&P) titled, "Temperature Control of the Operating Room", dated 6/2023, the P&P indicated this policy provides perioperative staff and facility leadership guidelines for room temperature range control within the surgical suite (includes clean / sterile storage ...). Environmental (room) temperature control is an essential part of infection control and a safe environment of care in the surgical suite. The hospital will control and monitor the environmental (room) temperature of areas within the surgical suite daily.