HospitalInspections.org

Based on observation, interview, record review and policy review, the hospital failed to:
- Ensure one Behavioral Health Unit (BHU) patient room was free from contraband (items that are illegal, forbidden, or that can be used to harm self or others); (A-0144)
- Ensure soap and excess paper towels were removed from three of four BHU dayrooms; (A-0144)
- Ensure a plastic trash bag was removed from a game available for patient use on the BHU; (A-0144)
- Ensure two of three seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) rooms in the BHU area had psychiatric safe screws; (A-0144)
- Ensure sharps were not available for patient or visitor access; (A-0144) and
- Ensure restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) were ordered by a licensed practitioner (LP) responsible for the care of one current patient (#36) and one discharged patient (#54) of four restrained patient records reviewed. (A-0168)

The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as an Immediate Jeopardy (IJ). As of 02/26/25, the hospital provided immediate action plans sufficient to remove the IJ when the hospital implemented corrective actions that included removing all excess paper towels from patient rooms and dayrooms.

This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation (CoP): Patient's Rights.

Please refer to A-0144 and A-0168.

Based on observation, interview, record review and policy review, the hospital failed to ensure:
- Nutritional supplements were not expired; (A-0749)
- Expired food was not available for patient use; (A-0749)
- Food was dated in patient nutrition rooms and in the kitchen; (A-0749)
- Food was covered in the kitchen freezer; (A-0749)
- Open beverages were not present in restricted areas; (A-0749)
- Staff beverage containers were spillproof; (A-0749)
- Earrings were contained in head covering in the Operating Room (OR); (A-0749)
- Clean all surfaces in the patient rooms during terminal cleaning; (A-0750)
- Clean all surfaces of the back area of the kitchen including the kitchen floors and ceilings; (A-0750)
- Clean the stove top and inside a food warmer; (A-0750)
- Clean the grill hood; (A-0750)
- Clean the stand-up mixer; (A-0750)
- Clean the cook prep table; (A-0750)
- Store the mixer blade in a clean area of the kitchen; (A-0750)
- Maintain the floor integrity in the kitchen; (A-0750)
- Empty the accumulated trash located in trash cans in kitchen; (A-0750)
- Remove personal items from the food prep service area in the kitchen; (A-0750)
- Clean all surfaces of the crash carts (mobile cart which contains emergency medical supplies and medication) on five units; (A-0750)
- Clean the microwave, refrigerators and coffee machines in the patient nutrition rooms; (A-0750)
- Clean the freezers in the Operating Room (OR) storage room; (A-0750)
- Clean the storage bins in the Obstetrics (OB, the branch of medical science concerned with childbirth and caring for and treating women in or in connection with childbirth) medication room; (A-0750)
- Clean point of care testing equipment between patients; (A-0750)
- Ensure multiple surfaces throughout the OR were in good repair and easy to clean; (A-0750) and
- Ensure Sterile Processing Department (SPD, area designated to clean, prepare, sterilize [process that eliminates viruses and bacteria], store and track reusable medical and surgical instruments or equipment) was free of dust accumulation. (A-0750)

The severity and cumulative effects of these systemic practices resulted in the hospital's non-compliance with 42 CFR 482.42 Condition of Participation: Infection Prevention and Control and Antibiotic Stewardship Programs and resulted in the hospital's failure to ensure quality health care and safety.

The hospital census was 307.

Based on observation, interview, record review and policy review, the hospital failed to ensure the safety of all patients when they failed to:
- Ensure one Behavioral Health Unit (BHU) patient room was free from contraband (items that are illegal, forbidden, or that can be used to harm self or others);
- Ensure soap and excess paper towels were removed from three of four BHU day rooms;
- Ensure a plastic trash bag was removed from games available for patient use on the BHU;
- Ensure two of three seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) rooms on the BHU had psychiatric safe screws; and
- Ensure sharps were not available for patient or visitor access.

Findings included:

Review of the hospital's policy titled, "Behavioral Health Precautions and Monitoring," dated 12/25/24, showed staff will conduct a search of patient belongings and environment, removing all potential self-harming objects. The most common form of self-harm is using a sharp object to cut one's skin. Other forms include, but are not limited to, behavior such as burning, scratching, swallowing foreign objects or hitting or banging body parts.

Observation on 02/24/25 at 1:45PM, in the dayroom on the Acute Care BHU, showed large stacks of paper towels and open soap bottles at the sink, accessible to patients.

Observation on 02/24/25 at 1:50 PM, in room 1010 on the Acute Care BHU, showed an unattended and unopened bottle of shampoo lying on a patient bed.

Observation on 02/24/25 at 1:50 PM, in the BHU's seclusion room between the Pediatric/Adolescent Unit and the Adult South Unit, showed four non-psychiatric safe screws in the restraint bedroom's door. When the door was closed, the screws faced the interior of the seclusion room and were accessible to patients.

Observation on 02/24/25 at 2:00 PM, showed an unused large trash bag lying on a shelf in an unlocked cupboard of the Intermediate BHU group therapy room.

Observation on 02/24/25 at 2:10 PM, in the Pediatric/Adolescent BHU seclusion room, showed two non-psychiatric safe screws that attached the face plate of the dead bolt lock to the door.

Observation on 02/25/25 at 1:50 PM, in the dayroom of the Pediatric/Adolescent BHU, showed large stacks of paper towels and open soap bottles, accessible to patients.

Observation on 02/25/25 at 1:55 PM, in the dayroom on the Intermediate Care BHU, showed large stacks of paper towels and open soap bottles at the sink, accessible to patients.

During an interview on 02/24/25 at 1:50 PM, Staff M, BHU Charge Registered Nurse (RN), stated that the seclusion room between the Pediatric/Adolescent Unit and Adult South Unit was used for pediatric, adolescent and adult patients.

During an interview on 02/24/25 at 1:50 PM, Staff A, RN Manager, stated that all patient rooms on the Acute BHU were left unlocked for patient access.

During an interview on 02/25/25 at 1:45 PM, Staff A, RN, stated that staff keep a "working knowledge" of what personal care items were in possession of the patients.

Review of the hospital's policy titled, "Needle and Sharps Safety," dated 04/23/24, showed sharps must not be left unattended or unsecured in patient care areas. After use all needles/sharps (including disposable needles, finger stick lancets, protected intravenous [IV, in the vein] catheter stylets, etc.) must immediately (or as soon as feasible) be disposed of in puncture resistant, leak-roof sharps containers located in each patient room and within patient-care departments.

Observation on 02/24/25 at 2:43 PM, on Five South, showed a large bin full of blood sugar lancets on the nurses' station counter unattended.

Observation on 02/25/25 at 12:10 PM, on Six North, showed three unused butterfly needles left in Patient #40's windowsill from a prior nurse attempt to draw blood cultures.

Observation on 02/25/25 at 11:50 AM, on Six North, showed Staff FFF, IV Therapy RN, left the used IV catheter stylet in the Patient #40's bed following insertion of an IV catheter.

During an interview on 02/24/25 at 2:43 PM, Staff X, Critical Care Director, stated that needles were not to have been left unattended at the nurses' station and could have been a safety risk to patients and visitors.

During interviews on 02/25/25 at 12:00 PM and 12:15 PM, Staff FFF, IV Therapy RN, stated that the catheter stylet should have been removed immediately after use and the butterfly needles should not have been left in the patient's windowsill.









46856




51292

Based on interview, record review and policy review, the hospital failed to ensure restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) were ordered by a licensed practitioner (LP) responsible for the care of one current patient (#36 ) and one discharged patient (#54) of four restrained patient records reviewed. This failure created an unsafe environment and had the potential to place all patients admitted to the hospital at risk for their safety.

Findings included:

Review of the hospital's policy titled, "Violent Restraint Utilization (for the Management of Violent or Self-Destructive Behaviors)," dated 08/15/24, showed that written orders for seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) or restraints for violent or self-destructive behaviors are limited to four hours for adults 18 years or older. If the order is about to expire and the Registered Nurse's (RN) assessment indicates that the patient requires continued restraint, the RN will contact the physician (or other LP if permitted by state law) and request that the original order be renewed for another period of time. Once a restraint is discontinued, reapplication constitutes a new episode and the procedure must start at the beginning, including a new order.

Review of Patient #36's medical record showed the following:
- On 02/23/25 at 2:13 PM, he was placed in a therapeutic hold (treatment technique in which a violent patient is physically contained by people).
- At 2:14 PM, he was placed in a restraint chair.
- At 2:23 PM, an order was obtained for the therapeutic hold and restraint chair.
- At 3:35 PM, he was released from the restraint chair and placed in seclusion.
- At 7:26 PM, a seclusion order was placed, three hours and 51 minutes after Patient #36 was placed in seclusion.
- At 10:14 PM, a seclusion order was placed.
- On 02/24/25 at 1:56 AM, a seclusion order was placed.
- At 6:06 AM, a seclusion order was placed.
- At 9:15 AM, a seclusion order was placed.
- At 1:15 PM, a seclusion order was placed.
- At 1:45 PM, he was released from seclusion.
- Patient #36 was in seclusion without an order for three hours and 51 minutes.

Review of Patient #54's medical record showed the following:
- On 10/01/24 at 2:05 PM, she was placed in four-point violent restraints (medical cuffs applied to both arms and both legs to prevent someone form causing harm to themselves or others).
- At 2:23 PM, a physician order was placed for four-point violent restraints.
- At 7:05 PM, she was placed in seclusion.
- There was no documentation that she was released from four-point violent restraints, nor was there an order for seclusion.
- At 11:00 PM, seclusion was discontinued. Patient #54 was in seclusion for a total of three hours and 55 minutes without an order.
- At 11:15 PM, she was placed in four-point violent restraints.
- There was no order for restraints.
- On 10/02/24 at 8:17 AM, a physician order was placed for four-point violent restraints. Patient #54 was in four-point restraints for nine hours and two minutes, without an order.
- At 9:30 AM, she was released from the restraints.

During an interview on 02/26/25 at 1:50 PM, Staff X, Nursing Manager, stated that if a patient remained in violent restraints, she expected nursing to follow hospital policy and have the order renewed every four hours. There were no restraint orders for Patient #54 on 10/01/24 at 2:23 PM through 10/02/24 at 8:17 AM.

During an interview on 02/27/25 at 1:12 PM, Staff RRRR, CNO, stated that all restraint and seclusion should have an order.

Based on observation, interview and policy review, the hospital failed to ensure:
- Nutritional supplements were not expired;
- Expired food was not available for patient use;
- Food was dated in patient nutrition rooms and in the kitchen;
- Food was covered in the kitchen freezer;
- Open beverages were not present in restricted areas;
- Staff beverage containers were spillproof; and
- Earrings were contained in head covering in the Operating Room (OR).

Findings included:

Although requested, the hospital failed to provide a policy that addressed expiration dates for nutritional supplements.

Observation on 02/24/25 at 2:35 PM, on unit two south, showed six bottles of nutritional supplements with expiration dates of 11/01/24 for three, 12/01/24 for one, 08/01/24 for one, and 06/01/24 for one.

During an interview on 02/24/25 at 2:35 PM, Staff S, Manager, stated that expired nutritional supplements should not be available for patient use.

During an interview on 02/27/25 at 12:30 PM, Staff WWW, Infection Preventionist, stated that food and nutritional items should be not expired.

Review of the hospital's policy titled, "Food Safety Policies and Standards," revised 10/01/24, showed refrigerated, ready-to-eat, food prepared and held in a food establishment must be clearly marked with a use-by/discard date. The use-by/discard date cannot exceed seven days as required in the FDA Retail Food Code with the day of preparation counted as day one.

Observation on 02/24/25 at 2:10 PM, on unit five south, in the nutrition room refrigerator, showed a wrapped sandwich with an expiration date that could not be read.

During an interview on 02/24/25 at 2:12 PM, Staff X, Critical Care Director, stated that the sandwich expiration date could not be read and should have been discarded.

Observation on 02/25/25 at 10:00 AM, on unit six north, in the nutrition room refrigerator, showed a wrapped sandwich with an expiration date 02/23/25.

Observation on 02/25/25 at 2:30 PM, in the kitchen, showed a dry flour bin with an expiration date of 02/04/25.

During an interview on 02/25/25 at 2:30 PM, Staff TT, Executive Chef, stated that the flour was expired and should be discarded.

Review of the hospital's policy titled, "Food Safety Policies and Standards," revised 10/01/24, showed food packaged by a food processing plant shall be clearly marked at the time the original container is opened. The date marked may not exceed the manufacturer's use-by date. Food that is required to be date marked must be discarded if it is in a container or package that does not bear a date or day or is inappropriately marked with a date or day that exceeds seven days. The manufacturer's expiration dates must be adhered to.

Observation on 02/25/25 at 2:30 PM, in the kitchen walk in freezer, showed one open bag of frozen vegetables, seven prepared frozen kosher meals, one open large bag of frozen raw ground beef patties and one open box of frozen country fried steak without open dates.

Observation on 02/25/25 at 2:45 PM, in the kitchen walk-in dairy refrigerator, showed one unopened bag of baby carrots without a manufacturer's use-by date and one open gallon jar of mayonnaise without an opened or best use-by date.

During an interview on 02/25/25 at 2:45 PM, Staff TT, Executive Chef, stated that the opened food packages or containers should have had a label with the date the product was opened and the best use-by date. Without the dates, they should be discarded.

Review of the hospital's policy titled, "Food Safety Policies and Standards," revised 10/01/24, showed foods frozen in the freezer unit must be properly covered and labeled with the date frozen and a use-by date. Food must be covered/protected from environmental contamination during storage.

Observation on 02/25/25 at 2:30 PM, in the kitchen freezer, showed one opened bag of frozen vegetables, seven prepared frozen kosher meals, one opened large bag of frozen raw ground beef patties and one opened bag of frozen country fried steak uncovered and unsealed.

During an interview on 02/25/25 at 2:30 PM, Staff TT, Executive Chef, stated that he agreed the opened and uncovered frozen food items should have been resealed in the plastic bags.

Review of the hospital's policy titled, "Food Safety Policies and Standards," revised 10/01/24, showed lockers or other suitable facilities must be provided for the storage of employee's possessions. Personal items may not be stored in a way that could contaminate exposed food or clean equipment.

Observation on 02/25/25 at 2:30 PM, in the kitchen, on the shelves under the prep table, showed staff members' personal drink containers and a step stool where food serving supplies were stored.

During an interview on 02/25/25 at 2:30 PM, Staff TT, Executive Chef, stated that he expected staff beverage containers to be stored in the designated area away from where food was prepared.

Observation on 02/25/25 at 2:48 PM, in the dish room, showed three personal drinks on the clean dishes shelf.

During an interview on 02/25/25 at 2:50 PM, Staff SS, General Manager, stated that personal drinks were not to be in the dish room.

During an interview on 02/27/25 at 12:30 PM, Staff WWW, Infection Preventionist, stated that personal drinks should be stored in the designated areas.

Observation on 02/24/25 at 2:49 PM, on unit three south, in the designated staff refreshment area located above the patient nourishment area, showed three open and uncovered staff drink containers. The patient nourishment area included the patient nourishment refrigerator, dried packaged patient food items and patient condiments in bins.

During an interview on 02/24/25 at 2:49 PM, Staff W, Registered Nurse (RN) Manager, stated that the staff drinks were "okay as long as they were located on the counter" in the designated staff nutrition area.

During an interview on 02/27/25 at 12:30 PM, Staff WWW, Infection Preventionist, stated that she expected employee drink containers to be covered and spill proof.

Review of the hospital's policy titled, "Surgical Attire," dated 07/08/24, showed all jewelry must be contained or confined within scrub attire.

Observation on 02/26/25 at 9:25 AM, showed Staff YYY, Circulating Nurse (role performed by a registered nurse who ensures the patient's safety during all phases of a surgical procedure); Staff ZZZ, Vendor; Staff AAAA, RN First Assistant (RNFA, nurse with specialized training to assist a physician); Staff BBBB, Surgeon; and Staff CCC, Scrub Nurse (nurse that assists the surgical team and passes instruments to the surgeon during surgery), wearing earrings not contained in their head covering while working in the OR.

Observation on 02/26/25 at 9:50 AM, showed Staff DDDD, Certified Registered Nurse Anesthetists (CRNA, registered nurses who have obtained graduate-level education and board certification in anesthesia); Staff EEEE, Scrub Nurse and Staff FFFF, Circulating Nurse, wearing earrings not contained in their head covering while working in the OR.

During an interview on 02/26/25 at 9:30 AM, Staff T, Surgical Services Director, stated that earrings were to be contained in the head covering.

During an interview on 02/27/25 at 12:30 PM, Staff WWW, Infection Preventionist, stated that earrings should be contained in the head covering while in the OR.










40189




50496

Based on observation, interview, record review and policy review, the hospital failed to:
- Clean all surfaces in the patient rooms during terminal cleaning;
- Clean all surfaces of the back area of the kitchen including the kitchen floors and ceilings;
- Clean the stove top and inside a food warmer;
- Clean the grill hood;
- Clean the stand-up mixer;
- Clean the cook prep table;
- Store the mixer blade in a clean area of the kitchen;
- Maintain the floor integrity in the kitchen;
- Empty the accumulated trash located in trash cans in kitchen;
- Remove personal items from the food prep service area in the kitchen;
- Clean all surfaces of the crash carts (mobile cart which contains emergency medical supplies and medication) on five units;
- Clean the microwave, refrigerators and coffee machines in the patient nutrition rooms;
- Clean the freezers in the Operating Room (OR) storage room;
- Clean the storage bins in the Obstetrics (OB, the branch of medical science concerned with childbirth and caring for and treating women in or in connection with childbirth) medication room;
- Clean point of care testing equipment between patients;
- Ensure multiple surfaces throughout the OR were in good repair and easy to clean;
- Ensure Sterile Processing Department (SPD, area designated to clean, prepare, sterilize [process that eliminates viruses and bacteria], store and track reusable medical and surgical instruments or equipment) was free of dust accumulation.

Findings included:

Review of the hospital's policy titled, "NAM-SOFT-CLEA_HLC_033_S_Operating Room _Surgical Invasive Areas and Delivery Rooms Terminal Cleaning at the End of Each Day," revised 03/2019, showed unused rooms should be cleaned once during each 24-hour period during the regularly scheduled work week. All surfaces were to be damp dusted. Staff were to spot wash walls and wall vents with the disinfectant solution.

Observation on 02/24/25 at 1:45 PM, rooms 334 and 335, in the Intensive Care Unit (ICU, a unit where critically ill patients are cared for), showed black marker writing, fingerprints and a sticky adhesive type of substance on the glass wall windows of the patient rooms.

During an interview on 02/24/25 at 1:45 PM, Staff U, Charge Registered Nurse (RN), stated that both rooms had been terminally cleaned and were ready to accept a patient. He expected the glass wall/windows of the patient rooms that are used to write down communication about the patient to be free of sticky residue and to be cleaned after a patient was moved from the room.

Review of the hospital's policy titled, "Food Safety Policies and Standards," revised 10/01/24, showed the materials for indoor floors, walls and ceiling surfaces must be smooth, durable and easily cleanable.

Review of the hospital's untitled and undated document, showed staff were to sweep and mop the floors daily.

Although requested, a completed kitchen cleaning log for the floors was not provided.

Observation on 02/25/25 at 2:20 PM, in the kitchen, showed the floors had debris and a buildup of a light and dark brown substances on the floor.

During an interview on 02/25/25 at 2:20 PM, Staff TT, Executive Chef, stated that the floors did not appear clean. They were to be cleaned daily in the evening.

Observation on 02/25/25 at 2:28 PM, in the kitchen, showed copious amounts of dust accumulation on all ceiling vents.

Observation on 02/25/25 at 2:32 PM, in the pot and pan room of the kitchen, showed copious amounts of dust accumulation on three ceiling vents.

Observation on 02/25/25 at 2:45 PM, in the dish room, showed copious amounts of dust accumulation on the ceiling vents.

During an interview on 02/25/25 at 3:05 PM, Staff TT, Executive Chef, stated that environmental services staff was responsible to clean the vents after hours on a monthly basis.

Review of the hospital's undated documented titled, "Food Safety Policies and Standards," revised 10/01/24, showed non-food contact surfaces must be cleaned at a frequency necessary to preclude the accumulation of soil residues. Cooking, baking equipment and the interior of microwave ovens must be cleaned and sanitized every 24 hours

Observation on 02/25/25 at 2:20 PM, showed the kitchen stove top surface was unclean and had a buildup of black charred debris.

During an interview on 02/25/25 at 2:20 PM, Staff TT, Executive Chef, stated that stove top was unclean and was to be cleaned daily.

Observation on 02/25/25 at 2:15 PM, in the kitchen, showed a food warmer with debris and dried liquid from a spill.

During an interview on 02/25/25 at 3:00 PM, Staff TT, Executive Chef, stated that the food warmer was cleaned weekly or as needed.

Review of the hospital's undated documented titled, "Table 11.4 Schedule of Inspection for Grease Buildup," showed systems serving high-volume cooking operations, such as 24-hour cooking, charbroiling or wok cooking were to be inspected quarterly.

Review of the hospital's undated document titled, "St. Louis Cleaning and Restoration," showed the kitchen hoods were cleaned on 05/30/24.

The kitchen hoods were not cleaned and inspected quarterly per hospital policy and were six months overdue. The hoods were due to be cleaned and inspected by 08/30/24 and 11/30/24.

During an interview on 02/25/25 at 2:20 PM, Staff TT, Executive Chef, stated that the hood appeared unclean and was last cleaned and inspected on 06/06/24. The next service would have been due in three months.

During an interview on 02/27/25 at 12:30 PM, Staff WWW, Infection Preventionist, stated that she expected the kitchen grill hoods to be cleaned on a regular basis and as needed. She expected them to be free of dust and grease drips.

Review of the hospital's untitled and undated document, showed staff were to clean, sanitize & wipe down the mixer after each use.

Although requested, a completed kitchen cleaning log for the mixer was not provided.

Observation on 02/25/25 at 2:30 PM, showed the large stand-up kitchen mixer had dust, dried debris and a powdery substance on the housing.

During an interview on 02/25/25 at 2:30 PM, Staff TT, Executive Chef, stated that the stand-up mixer appeared to be unclean. It was to be cleaned nightly.

During an interview on 02/27/25 at 12:30 PM, Staff WWW, Infection Preventionist, stated that she expected the stand-up mixer to be cleaned after each time a product was prepared.

Review of the hospital's undated documented titled, "Food Safety Policies and Standards," revised 10/01/24, showed non-food contact surfaces must be cleaned at a frequency necessary to preclude the accumulation of soil residues. The contact surface of the food preparation table is cleaned and sanitized at a frequency determined by regulatory code.

Observation on 02/25/25 at 2:30 PM, showed the cook prep table surface to be unclean with dust and debris. The shelves under the prep table had a step stool where food serving supplies were stored. Several metal brackets attached to the wall, hanging three feet over of the food prep table with dust and collections of a light brown liquid substance dripping onto the surface of the prep table.

During an interview on 02/25/25 at 2:30 PM, Staff TT, Executive Chef, stated that he was responsible for the cleaning schedule and if staff did not complete the items on the list, he counseled them. He would have expected the prep table surface to be cleaned after use, free of debris and personal items. The dirty wire racks should also be cleaned daily or removed from the wall as they were not being used.

Review of the hospital's policy titled, "Food Safety Policies and Standards," revised 10/01/24, showed clean equipment and utensils must be stored in a clean location, where they are not exposed to dust or other contamination.

Observation on 02/25/25 at 2:30 PM, in the kitchen prep area, showed the large wire stand up blender mixing paddle, stored on top of the warming oven, covered with dust particles.

During an interview on 02/25/25 at 2:30 PM, Staff TT, Executive Chef, stated that he was unsure why the wire mixing blade was stored on top of the warming oven. It should not have been stored there. It should have been stored on the rack in the clean equipment room, after it was cleansed and ready for use.

During an interview on 02/27/25 at 12:30 PM, Staff WWW, Infection Preventionist, stated that she would not expect the mixer blade to be stored on top of a dusty surface. IT should be stored in a clean area.

Review of the hospital's policy titled, "Food Safety Policies and Standards," revised 10/01/24, showed materials for indoor floors must be smooth, durable and easily cleanable.

Observation on 02/25/25 at 2:20 PM, showed the kitchen floor integrity was impaired. There were over 100 pea sized to three inch in diameter round holes in the epoxy flooring.

Observation on 02/25/25 at 2:35 PM, in several high traffic areas in the kitchen, showed large areas of the floor missing, making cleaning difficult.

During an interview on 02/25/25 at 2:20 PM, Staff VV, Client Executive District Manager, stated that a capital request had been placed for the floor replacement with heat rated epoxy to occur sometime before March.

Review of the hospital's policy titled, "Food Safety Policies and Standards," revised 10/01/24, showed the refuse and recyclable containers must be thoroughly cleaned at a frequency necessary to prevent them from build-up of soil or becoming attractant to pests, in a way that does not contaminate food, equipment, or utensils. Refuse and recyclables must be removed from the premises at a frequency that will minimize the development of objectionable odors and other conditions that could harbor pests.

Review of the hospital's untitled and undated document, showed the staff in the patient cook area of the kitchen were to empty the trash cans as needed.

Although requested, a completed kitchen cleaning log documenting trash removal was not provided.

Observation on 02/25/25 at 2:20 PM, showed the kitchen trash cans stored in between two heated ovens were full of plastic and paper trash.

During an interview on 02/25/25 at 2:20 PM, Staff TT, Executive Chef, stated that the trash cans are "emptied constantly" and "are not normally full of trash."

During an interview on 02/25/25 at 2:20 PM, Staff ZZ, Dietary Operations Manager, stated that the trash bins are "usually emptied every 20 minutes."

Review of the hospital's policy titled, "Food Safety Policies and Standards," revised 10/01/24, showed the lockers or other suitable facilities must be provided for the orderly storage of employee's possessions. Personal items may not be stored in a way that could contaminate exposed food or clean equipment.

Observation on 02/25/25 at 2:30 PM, in the kitchen, showed the prep table surface to be unclean with a wrist splint, paper and a clip board. The shelves under the prep table had a step stool where food serving supplies were stored.

During an interview on 02/25/25 at 2:30 PM, Staff TT, Executive Chef, stated that he would have expected the prep table surface to be clean. Paper items "ideally should not be" on the food prep table surface.

Review of the hospital's document titled, "Infection Prevention and Control for Safe Healthcare Delivery," dated 04/2024, showed to break the chain where germs live, staff will minimize or eliminate possible exposures by cleaning, disinfecting and sterilizing equipment.

Observation on 02/24/25 at 2:49 PM, on the ICU South unit, showed one crash cart with dust accumulation on the top.

Observation on 02/24/25 at 2:05 PM, on the OB unit, showed a crash cart with dust accumulation on the top.

During an interview on 02/24/25 at 2:05 PM, Staff Q, Family Birthplace Manager, stated that patient care staff cleaned the crash cart.

Observation on 02/24/25 at 2:40 PM, on two South unit, showed a crash cart with dust accumulation on the top.

During an interview on 02/24/25 at 2:40 PM, Staff S, Manager, stated that patient care staff cleaned the crash cart.

Observation on 02/26/25 at 9:50 AM, in the OR area, showed a crash cart with dust accumulation on the top.

During an interview on 02/26/25 at 9:50 AM, Staff T, Surgical Services Director, stated that OR staff cleaned the crash cart.

Observation on 02/26/25 at 10:18 AM, in the Endoscopy area, showed a crash cart with dust accumulation on the top.

During an interview on 02/26/25 at 10:18 AM, Staff XXX, Endoscopy Manager, stated that Endoscopy staff cleaned the crash cart.

During an interview on 02/27/25 at 12:30 PM, Staff WWW, Infection Preventionist, stated that she expected the crash carts to be free of dust.

Although requested, the hospital failed to provide a policy that addressed nutrition room equipment cleaning to include microwaves, refrigerators and coffee machines.

Observation on 02/24/25 at 1:50 PM, in the OB patient nutrition room, showed a dirty microwave that was for patient use only.

During an interview on 02/24/25 at 1:50 PM, Staff Q, Family Birthplace Manager, stated that staff were responsible to clean the microwave, and they tried to monitor it.

Observation on 02/24/25 at 1:50 PM, in the OB patient nutrition room, showed a refrigerator with debris on the inside and dried liquid from a spill.

During an interview on 02/24/25 at 1:55 PM, Staff Q, Family Birthplace Manager, stated that staff were to clean the refrigerator.

Observation on 02/24/25 at 2:23 PM, on unit two south, showed a refrigerator with debris on the inside and dried liquid from a spill.

During an interview on 02/24/25 at 2:32 PM, Staff S, Manager, stated that staff were to clean the refrigerator.

Observation on 02/24/25 at 1:55 PM, in the OB patient nutrition room, showed a coffee machine that had coffee grounds and dried liquid on and around the machine.

During an interview on 02/24/25 at 1:55 PM, Staff Q, Family Birthplace Manager, stated that she was not sure who cleaned the coffee machine.

Observation on 02/25/25 at 10:00 AM, on unit six north, showed a microwave with food splatters on floor and walls, coffee pots with brown stains and fingerprints, drawers with dirt and debris, and cabinet handles with dirt and debris.

During an interview on 02/25/25 at 10:00 AM, Staff P, Nurse Manager, stated that nursing was responsible for maintaining the nutrition area and it did not meet her expectations.

During an interview on 02/27/25 at 12:30 PM, Staff WWW, Infection Preventionist, stated that the equipment, including the microwave, refrigerator and coffee machine in the patient nutrition rooms should be clean.

Although requested, the hospital failed to provide a policy that addressed cleaning of the freezers in the OR.

Observation on 02/26/25 at 9:37 AM, in the OR storage room, showed two freezers with debris in the bottom.

During an interview on 02/26/25 at 9:37 AM, Staff T, Surgical Services Director, stated that there should be no debris in the bottom of the freezer and OR staff were responsible to clean the freezers.

During an interview on 02/27/25 at 12:30 PM, Staff WWW, Infection Preventionist, stated that the refrigerators and freezers should be clean.

Review of the hospital's document titled, "Infection Prevention and Control for Safe Healthcare Delivery," dated 04/2024, showed to break the chain where germs live, staff will minimize or eliminate possible exposures by cleaning and disinfecting equipment.

Observation on 02/24/25 at 2:00 PM, in the OB medication room, showed dust accumulation in the storage bins where supplies were kept.

During an interview on 02/24/25 at 2:00 PM, Staff Q, Family Birthplace Manager, stated that environmental services staff were responsible for cleaning the medication room.

Review of the hospital's policy titled, "Medication Administration," dated 02/16/24, directed staff to clean any equipment between patients.

Observation on 02/25/25 at 11:30 AM, showed Staff CCC, Care Partner, performed a point of care test on Patient #16 and then performed a point of care test on Patient #39. She failed to clean the machine between patient use.

During an interview on 02/25/25 at 11:40 AM, Staff CCC, Care Partner, stated that she cleaned the machine when she finished testing her assigned patients.

During an interview on 02/27/25 at 12:30 PM, Staff WWW, Infection Preventionist, stated that equipment should be cleaned between patient use.

Review of the hospital's policy titled, "NAM-SOFT-CLEA_HLC_033_S_Operating Room _Surgical Invasive Areas and Delivery Rooms Terminal Cleaning at the End of Each Day," revised 03/2019, showed furniture and cabinets are to be clean and free of dust.

Observation on 02/26/25 at 9:40 AM, in the storage room with sterile supplies, showed a large wooden cabinet with 40 small drawers. The drawers were chipped in areas and the back of the cabinet showed splintering wood pieces.

During an interview on 02/26/25 at 9:40 AM, Staff T, Surgical Services Director, stated that a wooden cabinet did not belong in a storage room with sterile supplies.

Observation on 02/26/25 at 9:38 AM, in the storage room with sterile supplies, showed peeling masking tape on the wire carts.

During an interview on 02/26/25 at 9:38 AM, Staff WWW, Infection Preventionist, stated that she was aware of the peeling tape and confirmed that cleaning the tape would be impossible.

Observation on 02/26/25 at 9:45 AM, in OR 6, showed a metal cabinet with a loose rubber seal inside the door and rust at the bottom of the cabinet.

During an interview on 02/26/28 at 9:45 AM, Staff T, Surgical Services Director, stated that the rubber seal should be intact and the rust should not be present.

Observation on 02/26/25 at 9:48 AM, in OR 7, showed adhesive residue on the outside of the door.

During an interview on 02/26/25 at 9:48 AM, Staff T, Surgical Services Director, stated that there should be no adhesive on the OR door.

During an interview on 02/27/25 at 12:30 PM, Staff WWW, Infection Preventionist, stated that OR should be free of dust debris and items should be with a smooth surface for cleaning.

Observation on 02/26/25 at 10:21 AM, in SPD, showed dust accumulation on the workstation where instruments were processed, on top of the file cabinets, at the pack and prep cabinets, on the copier and printer, and on the computer desk.

During an interview on 02/26/25 at 10:21 AM, Staff T, Surgical Services Director, stated that those areas should not be dusty. SPD staff were responsible to clean those areas.

Observation on 02/26/25 at 10:30 AM, in the pass-through window in SPD, showed shedding particle board around the base of the window.

During an interview on 02/26/25 at 10:30 M, Staff T, Surgical Services Director, stated that there should be no shedding around the window area.

During an interview on 02/27/25 at 12:30 PM, Staff WWW, Infection Preventionist, stated that SPD should be free of dust debris.








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