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A. Based on observation, document review and staff interview it was determined the facility failed to ensure fire-rate door assemblies in the means of egress were inspected and tested in accordance with National Fire Protection Association (NFPA) 101 (see Tag K 211); failed to ensure hazardous areas were protected and separated from other spaces in accordance with NFPA 101 (see Tag K 321); failed to ensure records of system testing for the fire alarm system were readily available in accordance with NFPA 72 (see tag K 345); failed to ensure the facility was protected throughout by an approved automatic sprinkler system in accordance with NFPA 13 (see Tag K 351); failed to ensure automatic sprinkler and standpipe systems were maintained in accordance with NFPA 25 (see Tag K 353); failed to ensure fire drills were held at least quarterly on each shift in accordance with NFPA 101 (see Tag K 712); failed to maintain and test electrical receptacles at patient bed locations in accordance with NFPA 101 (see Tag K 914); failed to ensure appropriate maintenance and testing of the emergency generator and associated equipment was performed in accordance with NFPA 110 (see Tag K 918); and, failed to ensure personnel had received the appropriate medical gas equipment qualifications and training in accordance with NFPA 99 (see Tag K 926).

B. Based on observation it was determined the facility failed to ensure the hospital environment is maintained in a such a manner that the safety and well being of patients are assured (see Tag 701).

Based on observation and staff interview it was determined the staff failed to monitor expiration dates on supplies and medicine used to provide patient care. This failure has the potential to negatively affect patients' healing process.

Findings include:

1. A tour of the the inpatient rehabilitation unit was conducted on 2/5/18 at approximately 1:15 p.m. During the tour, an inspection of the patient medication refrigerator revealed one (1) Pneumococal vaccine with an expiration date of 1/7/17, one (1) Tuberculin vaccine opened with no date or initials, nine (9) Tylenol 650 mg suppository with an expiration date of 10/17, one (1) Aspirin suppository with an expiration date of 1/18, two (2) Lactobacillus tablets with an expiration date of 10/25/16 and five (5) Bisacodyl suppositories with an expiration date of 7/17.

The above findings were verified with the Chief Nursing Officer on 2/5/18 at approximately 1:40 p.m.

2. While conducting a tour of the physical therapy unit on 2/6/18 at approximately 11:50 a.m., an inspection of the closet containing wound care supplies revealed one (1) tube of Collagenase Santyl ointment 250 units/gram with an expiration date of 11/15.

The above finding was verified on 2/6/18 at approximately 11:55 a.m. with the Inpatient Rehabilitation Manager.

3. An inspection of the patient supply area was conducted on 2/6/18 at approximately 1:00 p.m. During the inspection, seven (7) culture swabs were found with an expiration date of 7/17, one (1) Curity Iodoform Package Strip had an expiration date of 3/17, one (1) bottle of Hydrogen Peroxide had an expiration date of 7/17 and three (3) red-top Vacutainers had an expiration date of 5/17.

The above findings were verified with the Registered Nurse on 2/6/18 at approximately 1:45 p.m.

Based on observation, document review and staff interview it was determined the supervisor of the Dietetic Services failed to ensure all freezers and refrigerators were monitored to maintain temperatures within recommended ranges and failed to ensure policy and procedures were being followed. This deficient practice was identified in a walk-in refrigerator located in the kitchen storage area, a pull cooler refrigerator located in the kitchen storage area and a freezer located in the kitchen storage area. This failure has the potential to adversely affect all patients.

Findings include:

1. A tour of the Dietetic Services was conducted on 2/6/18 at 11:00 a.m. It was observed the temperature logs were incomplete for a freezer, walk-in refrigerator and pull cooler refrigerator located in the kitchen storage area. The freezer, pull cooler refrigerator and walk-in refrigerator logs were noted to have no initials of dietetic staff for completion of temperature checks for six (6) of eleven (11) temperature checks from 2/1/18 to 2/6/18. It was also observed the pull cooler refrigerator had a turkey located on the bottom tray with a pull date of 12/29/17. Further observation revealed the walk-in refrigerator had leftover food which was not wrapped securely and had no labeling.

2. A review of the policy and procedure titled "Food Storage", dated 2013, revealed it stated, in part: "All leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Temperatures should be checked at least two times a day."

3. An interview was conducted with the Executive Director on 2/7/18 at approximately 12:30 p.m. She stated all Dietetic Service staff are trained to initial and date all temperature checks and how to store food in the refrigerators. She concurred with the above findings.

Based on observation it was determined the facility failed to ensure the hospital environment is maintained in a such a manner that the safety and well being of patients are assured. This failure has the potential to adversely affect all patients. Facility census 13.

Findings include:

1. Observation during the facility tour on 02/07/18 at 11:20 a.m. revealed the kitchen dish room ceiling appeared stained with a mold/mildew substance.

2. Observation during the facility tour on 02/07/18 at 11:32 a.m. revealed the exhaust vent in the kitchen compressor room appeared loaded with dirt and debris.

3. Observation during the facility tour on 02/07/18 at 11:44 a.m. revealed the floor under and around the kitchen dish sink appeared soiled with grease and dirt.

4. The above findings were verified with the Plant Operations Director at the time of discovery and again with the Administrator at the time of exit.