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Based on observation, staff interview, and review of the facility's water management plan, the hospital failed to ensure facilities and equipment are maintained to ensure an acceptable level of safety and quality (A0724).

Based on observation, staff interview, review of the mechanical dishwasher logs, and review of the facility's water management plan, the hospital failed to ensure facilities and equipment are maintained to ensure an acceptable level of safety and quality. This could affect all patients receiving services from the facility. The active census was 79.

Findings include:

1. An interview was conducted with Staff A on 10/31/22 at 8:45 AM who reported the facility had a planned/scheduled repair to the boiler system that resulted in domestic hot water not being available for several hours on 10/26/22. Several days prior to the planned repair the facility informed all managers and staff via email of the expected hot water outage that was estimated to last several hours throughout the day. There had been no other times and/or dates the facility did not have adequate supply/delivery of hot water. The repairs took approximately six hours to complete on 10/26/22 and to date the facility has had no further disruptions to the hot water supply. This scheduled maintenance was carefully planned by administrative staff and contractors to limit the impact to staff and/or patients. The repairs were needed to ensure the boiler system remained reliable, safe, and efficient.

An interview was conducted with Staff C on 10/31/22 at 9:13 AM who reported in September 2022 the facility had a boiler that required an emergent repair. During that repair the contractors identified several issues within the boiler system that also needed to be repaired. This included an additional boiler, pipes, condensation lines, and pressure reducing valves. The additional repairs were scheduled/planned for 10/26/22 with an estimated time frame of eight hours to complete with an expected disruption to the hot water supply. This information was communicated to mangers and staff with resources available while the repairs took place. The facility conducted monthly testing of the hot water circulation pumps to check the time in seconds for hot water to reach an allowable temperature. The monthly testing of domestic hot water included temperature measurements to be taken from three to four random locations throughout the building. The temperature at the faucet must measure between 105 and 120 degrees Fahrenheit. The supervisor was to be notified immediately if the measurements occurred outside of the desired range.

Review of the water management plan revised 02/02/22 revealed hot water system temperature measurements were to be maintained between 105 and 120 Fahrenheit (F).

A tour of the facility was conducted on 10/31/22 at 3:20 PM with Staff C to conduct random testing of water temperatures from various locations to ensure hot water was being adequately supplied to the building. The following issues were identified at various locations throughout the building;

Unit 3 South room 324 the faucet sink water temperature measured 129 degrees F. This finding was confirmed with Staff C on 10/31/22 at 3:23 PM

Unit 2 South room 224 the faucet sink water temperature measured 126 degrees F. This finding was confirmed with Staff C on 10/31/22 at 3:28 PM.

Unit 2 West room 231 the faucet sink water temperature measured 128 degrees F. This finding was confirmed with Staff C on 10/31/22 at 3:33 PM.

Unit 2 West room 233 the faucet sink water temperature measured 125 degrees F. This finding was confirmed with the Staff C on 10/31/22 at 3:37 PM.

Unit 2 West room 234 the faucet sink water temperature measured 125 degrees F. This finding was confirmed with Staff C on 10/31/22 at 3:42 PM.

Unit 2 West room 235 the faucet sink water temperature measured 126 degrees F. This finding was confirmed with Staff C on 10/31/22 at 3:46 PM.

Unit 2 West room 236 the faucet sink had only cold water and no hot water. This finding was confirmed with Staff C on 10/31/22 at 3:53 PM.

Unit 2 West room 237 the faucet sink had only cold water and no hot water. This finding was confirmed with Staff C on 10/31/22 at 3:57 PM.

Unit 2 West room 238 the faucet sink had only cold water and no hot water. This finding was confirmed with Staff C on 10/31/22 at 4:04 PM.

Unit 2 West room 239 the water was tested from both the bathroom and room sink and confirmed only cold water at both faucets. This finding was confirmed with Staff C on 10/31/22 at 4:13 PM.

Unit 2 West room 240 the faucet sink had only cold water and no hot water. This finding was confirmed with Staff C on 10/31/22 at 4:17 PM.

Unit 2 West nursing station sink faucet had only cold water and no hot water. An interview was conducted with Staff I on 10/31/22 at 4:23 PM who reported hot water only worked in some of the rooms on the unit and had been a recent ongoing issue.

Staff C reported not being aware of the lack of hot water supply to the identified areas and/or the water temperature measurements exceeding the allowable range at the time of the observations.

2). A request was made to review the mechanical dishwasher logs which revealed repeated issues since 10/09/22 with the wash and rinse temperatures not being maintained according to manufacturer's recommendations. The logs indicated the Wash Temperature Minimum should equal 160 degrees F and the Rinse Temperature Minimum should equal 180 degrees F. The logs noted the dishwasher was not in use from 10/15/22 through 10/31/22 and was in use during the tour on 11/01/22 at 11:12 AM.

An interview was conducted with Staff J at the time of the tour who reported the temperatures were checked the morning of 11/01/22 and were within allowable ranges. A request was made to run a disk in the dishwasher to determine if temperatures were within the allowable ranges. During the observation, Staff J confirmed the wash cycle was 141 degrees F and per the manufacturer should be maintained at or above 160 degrees F during a wash cycle.

This deficiency represents non-compliance investigated under Substantial Allegation OH00137075.