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Based on observations and personnel interview, the facility failed to maintain readily available replacement solutions for treating emergency cases.

The findings included:

During the facility tours on 08/17/20 and 08/18/20, the following expired medications were observed:

Emergency Room:
-23 bags of 50 mL [milliliter] normal saline, expired on 02/2020
-Two Central dressing kits, expired 03/31/20
-Two Medivac tubing connectors, expired on 02/29/20
-Adult colorimetric CO2 detector, expired on 08/06/19

Cardiac Rehab- Two 10 mL normal saline flush syringes, expired on 12/2018

Surgical tour- Three bags of 1000 mL normal saline in the surgical medication refrigerator, expired on 07/2020.

The above was confirmed during the tours with Personnel 1, 11, and 14.

Based on observations and personnel interview, the facility failed to maintain readily available supplies commonly used in life-saving procedures.

The findings included:

During the facility tours on 08/17/20 and 08/18/20, the following expired supplies were observed:

Cardiac Rehab Crash Cart:
-Five IV Securement Start Kits, expired (exp) 03/2016
-Two IV Securement Start Kits, exp 05/2018
-Quick Combo AED pad, exp 08/08/18
-Two 20 Gauge [G] IV Catheter, exp 01/2016
-One 20G IV catheter, exp 02/2019
-Three 18G IV catheter, exp 01/2016
-Laryngeal Tube size 2.0, exp 03/2013
-Laryngeal tube size 2.5, exp 11/2015
-Laryngeal tube size 3.0, exp 02/2015
-Laryngeal tube size 4.0, exp 10/2015
-Laryngeal tube size 5.0, exp 10/2015

Operating Room:
-Eye Pad, exp 01/2010
-Eye Pad, exp 01/2014
-Two 18G needle, exp 06/18

Emergency Room:
-Two cuffed tracheal tube size 7.5, exp 05/2020

The above findings were confirmed during the tours with Personnel 1, 11, and 14.

Based on observations and personnel interview, the facility failed to maintain a system to ensure safety of patients.

The findings included:

A. The Code Blue button in the Cardiac Rehab area was pushed on 08/17/20. There was a greater than two minute response from facility personnel. The first response was Personnel 20, from the medical floor, who stated, "We couldn't find where the alarm was coming from."

If there was an emergency in the Cardiac Rehab area, the facility personnel were not able to respond in a timely manner. The above was confirmed by Personnel 11 on 08/17/20.

B. During a tour of the Physical Therapy Department on 08/17/20, review of the facility-based paraffin bath log, stated, "Temperature Range 118-130." Five of eight months, the temperature recorded was greater than 130 degrees. There was no indication personnel acknowledged the temperature was out of range.

In an interview on 08/17/20, with Personnel 21, when asked the temperature range of the paraffin bath, Personnel 21 reported, "It should be less than 130. It's not working correctly; we really need to look at getting a new one."

Personnel 21 confirmed the above findings on 08/17/20.

Based on review of personnel files, review of job descriptions, and personnel interview, the facility failed to ensure nursing staff providing care had current qualifications.

The findings included:

Personnel 1's job description stated in part, "Licensure and Certification: ...BLS [Basic Life Support] required
*ACLS, TNCE, PALS required [Advanced Cardiovascular Life Support, Trauma Nursing Core, Pediatric Advanced Life Support]."
Review of Personnel 1's file on 08/18/20 revealed ACLS expired 11/2019, PALS expired 10/2017, and TNCE expired 07/2019. Personnel 1 verified their certifications were expired.

Personnel 14's job description stated in part, "Position Qualifications -
Licensure and Certification:
*BLS, PALS, and ACLS
*Certified Wound, Ostomy, and Continence Nurse (CWCN) or Certified Wound Care Nurse (CWCN) required."
Review of Personnel 14's file on 08/18/20 revealed no BLS, PALS, ACLS, or CWCN. In an interview with Personnel 1 on the morning of 08/18/20, Personnel 1 reported that Personnel 14 was a new hire and completed BLS in July but had no card and had none of the other qualifications.

The above was confirmed in an interview with Personnel 1 on 08/18/20.

Based on observation and personnel interview, the facility failed to maintain a clean and sanitary environment.

The findings included:

During the facility tours on 08/17/20 and 08/18/20, the following were observed:

Surgery Department:
-In the decontamination room, dead bugs were in the light fixtures
-In the decontamination room, a cabinet door was broken off. The exposed splintered, sharp raw wood, had the likelihood to harm facility personnel. The raw wood made it difficult to keep clean.
-In the instrument room, there were missing barriers on the bottom shelves where instruments were being stored. When sweeping and mopping, barriers prevent splatter up to stored instruments.
-In the operating room, there were corrugated cardboard boxes, mixed with open sterile supplies.
-In the post-op area, the medication refrigerator had a large amount of dirty, brown buildup of ice in the freezer.

Central Supply (located in the basement):
-This area stored open clean and sterile supplies for the facility including sterile surgical supplies.
-There was no ceiling which exposed everything above, that included: water piping, electrical wiring, and an air conditioning unit.
-During an interview with Personnel 22, water from the air conditioning unit was dripping on the surveyor's head. The air conditioning unit had a black substance coming from the vents.
-Observed large five-gallon dirty bucket by the sterile gloves. When questioned about the bucket, Personnel 22 stated, "We had a 10-inch rain and it was catching the water that was leaking from the ceiling."
-Open packs of isolation gowns were stored on the top shelf in the area where the ceiling had leaked.
-One side contained a large, dirty, greasy water pump with exposed pipes that drained facility water out of the building.
-Corrugated cardboard boxes were stored over open sterile supplies.
-There were no barriers on bottom shelves where supplies were stored. When sweeping and mopping, barriers prevent splatter up to stored instruments.

Cardiac Rehab:
-Oscillating fan sitting on the floor was being held together by duct tape, which made it difficult to keep clean.

Throughout the facility, there were missing and water-stained ceiling tiles.

The nationally accepted standards set forth by the Association for the Advancement of Medical Instrumentation (AAMI) state, "External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust." (AAMI 5T46-Section 5.2 Receiving Items).

The above was confirmed during the tours with Personnel 1, 11, and 14.