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Based on document review and staff interview it was determined the facility failed to maintain a preventive maintenance program to ensure the safe operation of all mechanical, electrical, and patient care equipment. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7.

Findings include:

Document review on 11/15/22 at approximately 10:14 a.m. revealed no specific equipment maintenance inventories for all essential mechanical, electrical, and patient-care equipment was provided during survey.

Document review on 11/15/22 at approximately 10:28 a.m. revealed the equipment maintenance program was not based off of manufacturer recommendations or other generally accepted standards of practice for an alternate maintenance schedule.

Interview on 11/15/22 at approximately 10:29 a.m. with the Director of Plant Operations verified these findings. The findings were also acknowledged by the Executive Director at the exit interview on 11/15/22 at approximately 3:53 p.m.

Based on observation, document review, and staff interview, it was determined the facility failed to provide safety from fire and meet the provisions applicable to Existing Healthcare Occupancies of the 2012 edition of the Life Safety Code of the National Fire Protection Association (NFPA) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7.

Findings include:

In reference to Federal Life Safety Code citation K 324, the facility failed to ensure that cooking facilities were appropriately inspected.

In reference to Federal Life Safety Code citation K 353, the facility failed to ensure that the sprinkler system was appropriately inspected and maintained.

In reference to Federal Life Safety Code citation K 355, the facility failed to ensure that fire extinguishers were inspected monthly.

In reference to Federal Life Safety Code citation K 372, the facility failed to ensure that smoke and fire barriers were appropriately inspected and maintained.

In reference to Federal Life Safety Code citation K 712, the facility failed to ensure that fire drills were conducted at least quarterly on each shift.

In reference to Federal Life Safety Code citation K 781, the facility failed to ensure that portable space heaters were not used in health care occupancies.

In reference to Federal Life Safety Code citation K 914, the facility failed to ensure that patient bed location receptacles were appropriately tested.

In reference to Federal Life Safety Code citation K 918, the facility failed to ensure that the emergency generator was tested and maintained appropriately.

Interview on 11/15/22 at approximately 2:03 p.m. with the Director of Plant Operations verified these findings. The findings were also acknowledged by the Executive Director at the exit interview on 11/15/22 at approximately 3:53 p.m.

Based on observation and staff interview, it was determined the facility failed to ensure that facilities, supplies, and equipment were maintained to ensure an acceptable level of safety and quality. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7.

Findings include:

Observation on 11/14/22 at approximately 1:15 p.m. revealed the back wall in the walk-in cooler in the Kitchen appeared to be stained with a mold/mildew substance.

Observation on 11/14/22 at approximately 1:23 p.m. revealed the floors under the perimeter shelving in the walk-in cooler and freezer in the Kitchen were loaded with dust/debris.

Observation on 11/14/22 at approximately 1:32 p.m. revealed the registers of the ceiling mounted heating/cooling unit above the Preparation Area in the Kitchen appeared to be stained with a mold/mildew substance.

Observation on 11/14/22 at approximately 1:36 p.m. revealed ceiling tile which appeared to be stained/water damaged in the Kitchen Dish Room near the Dish Machine.

Observation on 11/14/22 at approximately 1:38 p.m. revealed the drop ceiling grid throughout the Kitchen Dish Room area was extensively rusty.

Observation on 11/14/22 at approximately 1:51 p.m. revealed the drain line to the three (3)-bowl sink in the Kitchen Dish Room was leaking onto the floor.

Observation on 11/14/22 at approximately 1:58 p.m. revealed the chemical storage cabinet in the Kitchen Dish Room was extensively rusty.

Observation on 11/14/22 at approximately 2:14 p.m. revealed a hole in the wall of the clean side of Laundry from a pre-existing dryer vent that was blocked off with a bath towel.

Observation on 11/14/22 at approximately 2:18 p.m. revealed the cart washer in the dirty side of Laundry was leaking with water running across the floor towards the washing machines.

Observation on 11/14/22 at approximately 2:27 p.m. revealed missing ceiling tile in the Central Supply area, above the wall mounted packaged terminal air conditioner (PTAC).

Observation on 11/14/22 at approximately 2:30 p.m. revealed ceiling tile, which appeared to be stained/water damaged in the Central Supply area.

Observation on 11/14/22 at approximately 2:34 p.m. revealed a drain pipe behind the syringe/needle storage rack in Central Supply, which appeared to be rusting and leaking water.

Observation on 11/14/22 at approximately 2:40 p.m. revealed a drain pipe in the Basement Clean Linen Storage Room that appeared to be rusting and leaking water onto the clean linen shelving, which also appeared to be rusting from the drain line leaking onto this shelving.

Interview on 11/14/22 at approximately 2:41 p.m. with the Director of Plant Operations verified these findings. The findings were also acknowledged by the Executive Director at the exit interview on 11/15/22 at approximately 3:53 p.m.

Based on document review and staff interview it was determined the facility failed to ensure proper ventilation in patient care areas. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7.

Findings include:

Document review on 11/15/22 at approximately 10:07 a.m. revealed no documentation of monitoring of the temperature, humidity, air changes, or appropriate air pressure relationships for critical areas throughout the facility was provided during survey.

Interview on 11/15/22 at approximately 10:08 a.m. with the Director of Plant Operations verified this finding. This finding was also acknowledged by the Executive Director at the exit interview on 11/15/22 at approximately 3:53 p.m.