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Based on policy and procedure review, Arkansas Code of 1987 (2023) Title 20 Public Health and Welfare (20-2-101---20-86-113) Subtitle 2 - Health and Safety (20-6-101---20-38-113) Chapter 27-Miscellaneous Health and Safety Provisions Subchapter 7 - Public Smoking 20-27-701---20-27-209) Section 20-27-706---Prohibition of smoking at medical facilities review, medical record review, observation and interview the facility failed to maintain a safe environment and comply with Federal, state, and local laws and regulations in that patients, visitors, and staff were provided an area and allowed to smoke on the grounds of a medical facility. This failed practice did not assure the physical safety of patients, visitors, and staff in the facility, did not assure patients, visitors, and staff entering the facility were not exposed to secondhand smoke and had the likelihood of affecting all patients, visitors and staff entering the facility. Findings follow:

A. Review of policy and procedure titled "Emergency Preparedness" with a revised date of 9/2011 and last dated 1/2024 showed, "Purpose-The purpose of the Safety Management Plan is to define the Safety Program to reduce the risk of injury to patients, staff, and visitors. Scope-The Safety Management Plan describes the programs used to design, implement and monitor a program to manage safety for patients, staff and visitors (for Named Hospital System) and to assure compliance with applicable codes and regulations." The policy goes on to state, "(Named Hospital System) has developed and maintains a policy prohibiting smoking on the premises' controlled by (Named Hospital System except in specified circumstances). This policy prohibits smoking in all areas of all buildings under the organizations' control."
B. Review of policy and procedure titled "Clean Air" with a revised date of 4/2018 showed, "Policy: (Named Hospital System) is committed to the health and wellbeing of its patients, guests, and staff members. In keeping with this commitment, (Named Hospital System) is maintaining a smoke free environment in an effort to aggressively address the health and medical issues associated with smoking. (Named Hospital System) does not provide designed smoking areas on the hospital campus. Those who choose to smoke must leave hospital property in accordance with Arkansas Code 20-27-204 and the Arkansas Clean Air Act."
C. Review of Arkansas Code of 1987 (2023) Title 20 Public Health and Welfare (20-2-101---20-86-113) Subtitle 2 - Health and Safety (20-6-101---20-38-113) Chapter 27-Miscellaneous Health and Safety Provisions Subchapter 7 - Public Smoking 20-27-701---20-27-209) Section 20-27-706---Prohibition of smoking at medical facilities showed, "Universal Citation: AR code 20-27-706 (2023) (a) Smoking of tobacco is prohibited on the grounds of all medical facilities. (1) Each medical facility shall request any person who violates subsection (a) of this section to desist. (2) If the violation continues, the medical facility may report the violation to the appropriate law enforcement agency."
D. A review of Patient #2's Medical Record showed, "Secondary Diagnoses: Tobacco Abuse Counseling."
E. A review of Patient #2's Case Management Note dated 10/11/2024 at 2:10 PM, showed, "Patient also shared that she smokes approximately a pack and a half of tobacco cigarettes a day."
F. A review of Patient #2's NSG (Nursing) RN (Registered Nurse) Observation Notes dated 10/11/2024 at 7:30 PM, showed, "Pt. (Patient) requested to go downstairs to smoke at least once this shift. Accompanied by (Named LPN (Licensed Practical Nurse)) and was off floor x 20 min."
G. During a tour of the facility on 1/14/25 at 1:00 PM, this surveyor observed a cigarette butt receptacle and 5-gallon bucket containing cigarette butts near the Emergency Room entrance to the facility.
H. The above findings were confirmed by the Director of Compliance, and she stated, "a lot of people in our community smoke."

Based on review of Medical Staff Bylaws, review of Infection Control Committee Meeting Minutes and interview, it was determined the facility failed to follow their Bylaws but not assuring the Infection Control Committee was chaired by a Physician Member of the Medical Staff , nor had a Physician Member of the Medical Staff attended any meetings for the last four of four (2/27/2024, 05/28/2024, 08/27/2024 and 11/26/2024) quarters. By not assuring a Physician Member Chaired the Committee and was involved in the committee proceedings, the facility was not following their Bylaws, to ensure the patients receive quality healthcare in a safe environment. Findings follow:

A. Record review of the Medical Staff Bylaws, revised 07/2022, showed the Infection Prevention Committee was to be chaired by a Physician Member of the Medical Staff.
B. Review of the Infection Control Committee Meeting Minutes for the last four quarters (2/27/2024, 05/28/2024, 08/27/2024 and 11/26/2024), showed that a Physician Member of the Medical Staff was not at any of the meetings nor involved in the committee proceedings.
C. During an interview on 01/15/2025 at 9:08 AM, the Director of Compliance verified there was not a Physician Member of the Medical Staff that chaired the Infection Control Committee.

Based on review of policy, review of Rules for Hospitals and Related Institutions in Arkansas (Revisions effective date: June 17, 2024), observation and interview, it was determined the facility failed to audit controlled substances in accordance with standards of practice in that two of two (Emergency and Medical/Surgical) Departments failed to audit for discrepancies at the end of each shift, per policy. By not auditing for discrepancies at the end of each shift, the facility could not assure nurses weren't leaving the building while there were pending discrepancies that should have been resolved, to prevent theft, loss and diversion. This failed practice had the likelihood to affect all patients in the hospital. Findings follow:

A. Record review of the facility's policy titled "Controlled Substances," revised 03/2024, showed that staff were to resolve any discrepancies by the end of their shift. (If a shift does not audit for discrepancies prior to leaving for the day, those discrepancies remain unresolved and become harder to reconcile, therefore harder to prevent loss, theft and diversion.)
B. Review of the Rules for Hospitals and Related Institutions in Arkansas (Revisions effective date: June 17, 2024) Section 12 Medications, showed there shall be an audit each shift of all controlled substances, by the oncoming nurse and witnessed by the off-going nurse. (This practice ensures the off-going nurse was not leaving any discrepancies and the on-coming nurse was not inheriting any discrepancies.)
C. During a tour of the Medication Rooms on 01/14/2025 from 12:30 PM to 1:00 PM, observation showed:
1. Medical/Surgical Department was able to provide evidence in the Automated Dispensing Machine, the shift audit of Controlled Substances was done in the morning.
2. Emergency Department was able to provide evidence in the Automated Dispensing Machine, the shift audit of Controlled Substances was done in the morning.
D. During an interview on 01/14/2025 at 12:45, the Medical/Surgical Department RN Charge Nurse verified they only do shift audits of Controlled Substances in the mornings. The Facility has two 12-hour shifts, and there was not one done in the evening.
E. During an interview on 01/14/2025 at 1:00 PM, the Emergency Department Director verified they only do shift audits of Controlled Substances in the mornings. The Facility has two 12-hour shifts, and there was not one done in the evening.

Based on observation, review of policy and interview, it was determined the facility failed to ensure floor stock was properly controlled in one of one Radiology Services toured in that prescription contrast agents (used for X-ray imaging) were observed in a cabinet that was not secured. The prescription medication was unsecured and accessible to unlicensed personnel. By not controlling floor stock, the facility could not assure the safety, integrity or efficacy of the uncontrolled prescription contrast agents. The failed practice had the likelihood to affect all patients that received radiological services this facility. Findings follow:

A. Record review of the facility's policy titled, "Storage," approved 03/2022, showed all prescription drugs shall be stored securely.
B. During a tour of Radiology Services on 01/15/2025 from 9:35 AM to 10:04 AM, observation showed the following in the CAT scan room, in an open cabinet:
1. #5 ISOVUE 370 - 100 ml (milliliters) vials;
2. #3 ISOVUE 300 - 100 ml vials;
3. #15 Omnipaque - 500 ml containers; and
4. #5 Berry Smoothie Readi-Cat 2 - 450 ml containers.
Also, during this observation EVS (Environmental Services) employee #1 was changing the trash out in the room. The unsecured prescription contrast agents were available to unlicensed personnel.
C. During an interview on 01/15/2025 at 9:57 AM, the Manager of Radiology verified the findings at B.

Based on policy and procedure review, job description review, personnel file review, committee meeting minutes review, observation and interview, it was determined that the facility failed to have a facility wide infection prevention and control and antibiotic stewardship program in that the facility failed to ensure:
1. The Infection Control Preventionist had training or certification in infection prevention or control.
2. Hand hygiene was being monitored in the facility.
3. Maintaining a clean and sanitary environment throughout the hospital.
4. Communication and collaboration with the Quality Assessment and Performance Improvement (QAPI) program with accurate reporting data.

The failed practices promoted the spread of infection and did not ensure the facility had an effective infection prevention and control program or antibiotic stewardship program in place. The failed practices had the likelihood of affecting all patient receiving care in the facility. See O-0462, O-0464, O-0466, and O-0480 for details.

Based on job description review, employee file review, and interview it was determined the Infection Control Preventionist had no training or certification in infection prevention or control. The failed practice did not allow the facility to have a trained or certified individual overseeing the infection control program and had the likelihood of affecting all patients in the facility and employees. Findings follow:

A. Review of Infection Preventionist Job Description, Competency, and Performance Appraisal policy revised date of 10/2018, showed the job summary " ...Infection Control Nurse is responsible for the surveillance, analysis, interpretation and reporting of hospital acquired infections (HAIs); educating employees about infection prevention; and the development of health system policies and procedures to ensure rigorous infection control standards that meet Joint Commission on Accreditation of Healthcare Organizations (JCAHO), Occupational Safety and Health Administration (OSHA), Centers for Medicaid/Medicare Services (CMS), Centers for Disease Control and Prevention (CDC), and other nationally organized agencies recommendations and requirements. Qualifications: Must be a graduate of an approved School of Nursing and have a valid Registered Nurse License and a valid Basic Life Support Certification plus have five years of clinical experience, preferred experience in infection control or quality. Must have the ability to analyze, interpret and display data, excellent communication skills, ability to work independently. Proficient in Microsoft Office Products.

B. Review of Infection Control Preventionist education folder on 01/14/25 at 8:45 AM, showed no training or certification in infection prevention or control by a nationally recognized organization.
1. Infection Control Preventionist provided 4 live webinars certificates from (Named) & Associates, which were not nationally recognized.
2. Infection Control Preventionist provided five National Healthcare Safety Network (NHSN) Certificates of Completion toward the 2024 NHSN through Centers for Disease Control and Prevention. The 2024 NHSN syllabus contains 4 pages of training videos and slides

C. Review of the 2024 National Healthcare Safety Network Patient Safety Component Annual Training Certificates on 01/14/25 at 8:45 AM, showed that the Infection Control Preventionist completed five video training (2 hours and 48 minutes) of the 21 hours and 3 minutes required.

D. In an interview with the Infection Control Preventionist on 01/14/25 1:07 PM, she stated that she has not been to Association of Professionals in Infection Control (APIC) and Epidemiology training or Centers for Disease Control and Prevention training for infection control. She stated that "last year she had planned to go get her certification through APIC, however, it was rescheduled and has not gone yet."

Based on policy and procedure review, Infection Control Committee Meeting minutes, and interview, it was determined that the infection control prevention and control program did not ensure that hand hygiene was monitored by the facilities written policies. The failed practice had the likelihood of transmitting infections throughout the hospital and had the likelihood of affecting all patients receiving care. Findings follow:

A. Review of Performance Improvement Monthly Report dated 12/2024, showed the monthly compliance for hand hygiene was 100%.
B. Review of the Performance Measures for 2024 for hand hygiene showed 100% compliance for all 4 quarters.
C. Review of Hand Hygiene Performance Improvement Tool for January through December, showed that each manager of the different departments in the hospital had observed 10 employees washing their hands.
D. In an interview with the Infection Control Preventionist (ICP) on 01/15/25 at 8:30 AM, the surveyor asked about how they could be at a 100% compliance for hand hygiene for the year 2024. She stated that she looked at the Hand Hygiene Performance Improvement Tool to monitor which of the managers completed the tool and added how many managers observed their employees each month. The surveyor reviewed each monthly hand hygiene tool from each manager. Several of the managers had completed the tool however, the number of employees that had not washed their hands did not equate to a 100% hand washing compliance. The ICP stated that she should have been looking at the comments section from the hand hygiene tool to find out why the employees were not washing their hands.
E. The findings in A-D were confirmed by the Infection Control Preventionist.

Based on review of policy, observation, and interview, it was determined the facility failed to maintain the medication room medication preparation areas clean and sanitary, per policy, in one (Emergency Department) of two (Medical/Surgical and Emergency) Departments toured. By not keeping the medication preparation area clean and sanitary, the facility could not assure the avoidance of sources and transmission of infections. This failed practice had the likelihood to affect all patients receiving medications from this patient care area. Findings follow:

A. Record review of the facility's policy titled, "Hospital Areas General Responsibilities Medicine Room," showed the Medication Room should be cleaned at least daily. Cleaning material should be disinfectant and floor cleaner. Tools and equipment should be microfiber cloth, microfiber mopping unit, dustpan, hand brush and plastic can liners (for trash). The frequency should be daily and as needed. The methods should be: removing trash, disinfecting and relining container, clean the sink with disinfectant, clean pipes and fixtures, clean walls around sinks, clean cabinets, lights, paper towel dispenser and all ledges and wet mop with a floor cleaning solution.
B. During a tour of the facility on 01/13/25 from 1:13 PM to 2:07 PM, observation showed the Emergency Room Medication Room's medication preparation area staged over a dirty sink. A piece of dirty Plexiglas was set over a dirty sink. There were 23 vial tops scattered on the bottom of the sink, a Band-Aid wrapper, scraps of foil packaging along with white and tan dried solutions in the sink, on the Plexiglas and counter. There were liquid splashes that were strewn down the wooden cabinetry. The cabinetry supporting the sink was made of wood that was worn, faded and unable to be sanitized due to it being porous. The floors had visible accumulated dirt.
C. The findings were verified at the time of observation by the Director of Compliance.


46733

Based on policy and procedure review, observation, and interview, the Certified Dietary Manager (CDM) failed to maintain food safety/sanitation for 3 of 3 bulk items (sugar, flour, and cornmeal) in 1 of 1 kitchen in that the bulk items were in metal cabinet bins that opened downward not in a glass or plastic container with a secured lid. The bins each had a label applied to them which was dated. The label did not state whether this was the date the product was placed in the bin or if it was the expiration date of the product. This failed practice did not ensure the bulk items were not contaminated by staff and free from insect and vermin contamination and did not ensure that expired sugar, flour, or cornmeal was not used to prepare food that was consequently served to patients, visitors or staff members. This failed practice had the likelihood of affecting anyone served meals that had been prepared with the sugar, flour, and cornmeal. Findings follow:

A. Review of policy and procedure titled, "Purchasing, Receiving and Storage" last revised on 7/2024 showed, "Storage: Broken lots of bulk foods are stored in heavy plastic or glass containers with tight fitting lids."
B. During a tour of the kitchen on 1/14/25 at 9:58 AM, there was a row of metal cabinets which contained 3 bins that opened downward. One of the bins contained bulk sugar, one contained bulk flour, and one contained bulk cornmeal. These items had all been poured into the bins and were not contained in any type of packaging. Each bin had a label applied on the outside with a date written on the label.
C. In an interview with the CDM at the time of the observation she stated the bulk dry goods were emptied from 25-pound bags into the bins. She stated the date on the labels on the bins was the date the bulk goods were emptied into the bins. She stated the dry goods were used from the bin until it was empty, then the bins were cleaned and refilled with a new dated label placed on the bin. She could not state when the bulk goods expired. She confirmed all of these findings in A, B, and C at the time the observation and interview occurred.




50014

Based on policy and procedures review, observation and interview, it was determined that the facility failed to maintain a clean and sanitary environment in the Emergency Department (ED), the Medical Surgical floor, the Radiology suite, and stairwell. By not assuring cleanliness and sanitary environments, the facility could not prevent transmission of infections. The failed practice had the likelihood of affecting all patients who were seen in the hospital. Findings follow:

A. In an interview with Environmental Services Supervisor on 01/14/2025 at 2:00 PM, she stated that "the patient rooms should be cleaned daily; however there have been staffing issues over the past month because we had to let someone go."
1. Observed rust on table and 2 Intravenous poles in the Emergency Department on 01/13/2025 at 1:30 PM.
2. Porous tape on Trauma Room 4 door, sharps container in trauma room, trash can, Intravenous stand, and a computer with wheels on 01/13/2025 at 1:35 PM.
3. Observed dirty floor in Room 9 on 01/13/2025 at 1:40 PM
4. Observed clean and dirty supplies in the Emergency Medicine Technician room on 01/14/2025 at 1:45 PM.

B. Review of the facility's policy titled, "Hospital Areas General Responsibilities Sink-Washbowl," with revision date of 07/2018, showed the procedures for cleaning Sink-Washbowl. "Cleaning materials: Disinfectant; Tools and Equipment: Cloths; Frequency: Two times a day. ... Use a cloth with cleanser and wash both interior and exterior of sink. Wash with detergent solution faucets, soap dishes, plumbing pipes."
1. On 01/13/2025 at 1:35 PM, observed a white sink in the ED that was covered in a rust like color substance that encompassed the bottom and all 4 sides of the sink-washbowl.
2. On 01/13/2025 at 2:20 PM, observed a dirty sink in the Antepartum room on the Medical Surgical floor.
3. On 01/15/2025 at 10:15 AM, observed a dirty sink in the Radiology Suite.

C. Review of the facility's policy titled, "Radiology Services Policy and Procedure 25.1" revised date of 02/2024, showed that "All rooms are cleaned by Environmental Services personnel on a daily basis and when otherwise indicated by environmental contaminations of blood or body fluids."
1. On 01/15/2025 at 9:56 AM, observed a dirty sink in the Radiology Suite.
2. Verified with Radiology Manager on 01/15/2025 at 9:57 AM.

D. Review of the facility's policy "General Policy and Procedure: Storage of Supplies" with revision date of 02/024, stated that "soiled objects cannot contaminate those that are clean or sterile. Separate areas for storage and handling of soiled items and clean/sterile items are maintained."
1. Biohazard trash can with waste found in storage room with clean supplies in the ED.
2. Computer on wheels in storage room, unknown if clean or dirty in the ED.
3. 10-12 empty cardboard boxes piled on top of each other in the ED.
4. In an interview with the Quality Director on 01/15/2025 at 9:30 AM, she stated that "this room was a catchall."
5. The findings were verified with the Quality Director.

E. Review of the facility's policy "Decontamination of Trash Containers and Transport Carts," with revision date 03/2012, showed that "trash is collected daily by Environmental Services staff." The procedure .... "Flat bed dolly used for transporting Bio-Hazard waste tubs will be disinfected daily."
1. Observation showed a biohazard trash can with waste in the Emergency Medical Technician room with clean supplies.

F. Review of the facility's policy, "Environmental Services Policy and Procedure #13.0," revised on 2/2024, showed for "cleaning non-patient areas: The stairwells should also be cleaned weekly or as needed by beginning at the top and working down. They are wet mopped once daily. Trash needs to be picked up and damp dusting done on ledges and railings."
1. Observation on 01/13/2025 at 2:15 PM, showed the stairwell across from the Quality Directors office that leads to Medical Surgical Floor, had 10-30 dead flies and dead spiders on the floor under the stairwell light.
2. In an interview with Environmental Services Supervisor on 01/14/2025 at 2:00 PM, she stated that "she saw the dead bugs about an hour ago and cleaned them up."

Based on an interview, it was determined that the Infection Control Preventionist (ICP) was not reporting accurate hand hygiene information to the Quality and Assurance Performance and Improvement committee. By not assuring that hand hygiene was being monitored monthly, the failed practice promoted the spread of infection. The failed practice had the likelihood of affecting all patients who were seen in the hospital. Findings follow:

A. Review of Performance Improvement Monthly Report dated 12/2024, showed the monthly compliance for hand hygiene was 100%.
B. Review of the Performance Measures for 2024 for hand hygiene showed 100% compliance for all 4 quarters.
C. Review of Hand Hygiene Performance Improvement Tool for January through December, showed that each manager of the different departments in the hospital had observed 10 employees washing their hands.
D. In an interview with the Infection Control Preventionist on 01/15/25 at 8:30 AM, the surveyor asked about how they could be at a 100% compliance for hand hygiene for the year 2024. She stated that she looked at the Hand Hygiene Performance Improvement Tool to monitor which of the managers completed the tool and added how many managers observed their employees each month. The surveyor reviewed each monthly hand hygiene tool from each manager. Several of the managers had completed the tool however, the number of employees that had not washed their hands did not equate to a 100% hand washing compliance. The ICP stated that she should have been looking at the comments section from the hand hygiene tool to find out why the employees were not washing their hands.
E. The findings of A-D were confirmed by the Infection Control Preventionist.

Based on policy and procedure review, job description, competency, and performance appraisal review, Initial Competency Assessment Tool review, observation, and interview the facility failed to ensure four of four (#1-#4) Ward Clerk-Monitor Techs received the telemetry training and were qualified to monitor telemetry on one of one Medical/Surgical Observation Unit. The failed practice did not assure that patients with ordered telemetry monitoring received care in a safe setting and did not ensure that staff could recognize dysrhythmias and notify nursing personnel immediately. This failed practice had the likelihood of affecting all patients on the Medical/Surgical Observation Unit with ordered telemetry. Findings follow:

A. Review of policy and procedure provided by the facility titled, "Care of The Patient Requiring Cardiac Monitoring" described the process of preparing skin for application of the EKG (electrocardiogram) leads, selection and positioning of the leads, troubleshooting equipment issues, daily assessment of the skin at the sites for irritation, documentation, and removal. This policy and procedure did not address training for staff in cardiac rhythm interpretation and intervention.
B. Review of a document titled, "Job Description, Competency, and Performance Appraisal" for Ward Clerk-Monitor Tech showed, "4. Cardiac Monitor Tech: a. Monitors cardiac monitor, verifies the orders, identifies/responds and alerts nurses to abnormal EKG rhythms, troubleshoots alarms, enters patient information into monitor system, places rhythm strips on charts and maintains patient rhythm logs appropriately."
C. Review of a document titled, "Initial Competency Assessment Tool" showed, "CR 5 Cares for a Patient Requiring Cardiac Monitoring: Identifies/responds to abnormal EKG rhythms, notifies appropriate nurse of abnormal EKG rhythms as needed."
D. Review of the Initial Competency Assessment Tools for Ward Clerk-Monitor Techs #1, #2, and #3 showed validation dates of 10/24/24, 11/10/24, and 10/2/24 respectively.
E. Review of Competency Assessment Tool for Ward Clerk-Monitor Tech #4 showed, "demonstrates an understanding of lethal rhythms and notifies the appropriate staff of rhythm. Completion of an EKG class. Post telemetry strips in chart at beginning and end of shift" verified on 11/5/23.
F. During a tour of the Medical/Surgical Observation Unit on 1/14/25 at 9:45 AM, Ward Clerk-Monitor Tech #4 was observed behind the desk at the Nurses Station facing away from the Telemetry Monitor. She was alone behind the desk and there were no Nurses present. She stated the Ward Clerk-Monitor Techs were trained to perform 12-lead EKGs on patients that have been sent over as outpatients from the physician's office. She stated they were not trained in telemetry monitoring but if the monitor alarms and the strip "looks irregular to me" I will go and get the Nurse. At least two times during the observation/interview the monitor alarms went off and Ward Clerk-Monitor Tech #4 did not get up and go and notify a Nurse.
G. In an interview with the Medical Surgical Director on 1/15/25 at 9:30 AM, she stated there are 8 rooms that have the capability for telemetry monitoring. The RN (Registered Nurse) oversees the monitors, and the Ward Clerk-Monitor Techs and Licensed Practical Nurses (LPNs) have been educated on monitoring and printing monitoring strips and placing them in the medical records. The process for telemetry monitoring was that if the Nurses are not at the Nurses Station to watch the monitors, then the Ward Clerk-Monitor Techs are responsible for watching the monitors. If the monitor alarms, they are supposed to notify Nursing staff. This surveyor asked the Medical Surgical Director to provide the policy and procedure for the Telemetry Monitoring on the unit and the course materials that provided evidence that the Ward Clerk-Monitor Techs have been trained to read/interpret dysrhythmias. She stated she could not provide the policy and procedure and that the Ward Clerk-Monitor Techs did not have any documented dysrhythmia training and could not provide any course material for training. She said the Nursing staff had just shown them what to watch for. She confirmed the findings in A-F during the interview.

Based on review of policy, observation and interview, it was determined the facility failed to maintain a piece of equipment in clean and working order for one of one Rehabilitation Department Cold Pack Freezer, per policy. By not maintaining the equipment, the facility could not ensure the safety and quality of care due to the state of this piece of equipment. The failed practice had the likelihood to affect all patients who receive Rehabilitation Services at the facility. Findings follow:

A. Review of the Facility policy titled "Treatment Area and Equipment Cleaning," Revised 01/2023, showed the Cold Pack Machine should be cleaned monthly. The racks and packs were to be removed, and the racks and all the inside surfaces of the tank scrubbed with a hospital approved germicidal disinfectant.
B. During a tour of Rehabilitation Services on 01/15/25 at 10:47 AM, observation showed the Cold Pack Machine's door to be busted and cracked in several areas, the rubber seal not attached in areas, and the foam insulation of the door exposed. The door did not shut all the way and there was a buildup of thick ice several inches down the inside walls and creeping out onto the edge where the seal would normally sit tight. The condition of this door did not allow for a tight seal for proper functioning, nor did it allow it to be cleaned thoroughly as foam insulation cannot be sanitized.
C. During an interview on 01/15/25 at 10:57 AM, the Director of Rehabilitation Services verified the condition of the Cold Pack Machine. They also verified they do not clean it according to policy.

Based on observation, review of National Fire Protection Agency (NFPA) 101 standards , review of facility maintenance logs and interview, it was determined the facility failed to provide battery-powered emergency lighting for the generator. The failed practice had the likelihood to affect all patients and staff in that in the event of a power outage emergency there would be no lighting to illuminate the generator work area. Findings follow:

A. Review of NFPA 101, 2012 guidelines showed, 1) Requirement: Emergency lighting must be provided in all areas where it is necessary for the safety of building occupants in the event of a power failure. This includes illumination for exit routes, exits, and specific areas of the building like stairs or corridors. (chapter 7)
B. Observation of the generator on 1/13/2025 at 1:54 PM showed there were no functioning batteries present in the generator backup lights.
C. The findings of A and B were verified with the Director of Plant Operations 1/14/2025 at 3:15 PM.

Based on review or facility maintenance records, review of National Fire Protection Agency (NFPA) standards, observation and interview it was determined the facility failed to:

1. Conduct ceiling tile checks monthly.
2. Conduct water temperature checks weekly.
3. Ensure fire extinguishers checks were logged or checked monthly.
4. Ensure exhaust fans were checked monthly.
5. Ensure emergency exit light checks were conducted monthly.
6. Conduct wall penetration checks monthly
7. Ensure emergency door checks were conducted.

The failed practice did not ensure a safe environment for the patients and staff and had the likelihood to affect all patients receiving care in the facility and staff. Findings follow:

A. Review of NFPA standards showed the following:
1) NFPA requirements for conducting ceiling tile checks, as outlined in NFPA 101 (Life Safety Code), stipulate that ceiling tiles must be inspected regularly to ensure they are properly secured and do not obstruct fire protection systems, such as sprinklers, or interfere with safe egress routes.
2) NFPA requirements for conducting water temperature checks, as outlined in NFPA 13 (Standard for the Installation of Sprinkler Systems), mandate that the water temperature in sprinkler systems must be regularly checked to ensure it remains within the specified range to prevent freezing or damage to the system, ensuring its reliable operation in an emergency.
3) NFPA requirements for conducting fire extinguisher checks, as outlined in NFPA 10 (Standard for Portable Fire Extinguishers), mandate that fire extinguishers must be inspected monthly to ensure they are fully charged, properly mounted, and free of obstruction, with a thorough annual maintenance check to verify their operational readiness.
4)NFPA guidelines for wall penetration checks focus on maintaining the fire-resistance integrity of walls. Any penetration through fire-rated walls, such as pipes, cables, or ducts, must be sealed with approved firestop materials that match the fire-resistance rating of the wall. Regular inspections are required to ensure the firestopping remains intact, and any damage or deterioration must be repaired immediately to prevent the spread of fire and smoke.
5) NFPA requirements for conducting exhaust fan checks, as outlined in NFPA 90A (Standard for the Installation of Air-Conditioning and Ventilating Systems), mandate that exhaust fans be regularly inspected and tested to ensure they are operating properly, free of obstructions, and capable of effectively ventilating smoke or fumes during an emergency.
6) NFPA requirements for conducting emergency light checks, as outlined in NFPA 101 (Life Safety Code), mandate that emergency lighting systems be tested monthly to ensure they are operational, with a full-duration test conducted annually to verify they provide adequate illumination for at least 90 minutes during a power outage.
7) NFPA requirements for conducting emergency door checks, as outlined in NFPA 101 (Life Safety Code), mandate that emergency doors be inspected regularly to ensure they are unobstructed, properly functioning, and capable of being opened easily without the use of a key or special knowledge, especially during a fire or evacuation situation.


B. Review of facility maintenance records on 1/13/2025 at 1:00 PM showed the following:
1) There was no evidence the facility conducted ceiling tiles checks
2) There was no evidence the facility conducted water temperature checks
3) Fire extinguisher checks weren't logged correctly monthly
4) There was no evidence of exhaust fan checks
5) There was no evidence of emergency exit light checks
6) There was no evidence of fire wall penetration checks
7) There was no evidence of emergency door checks

C. The finding of A and B were verified with the Director of Plant Operations on 1/14/25 at 3:00 PM



Based on observation of the kitchen, Emergency Department, and interview, it was determined the facility failed to maintain the building physical structure, safety, environment, and equipment in a state of good repair. The failed practice promoted the spread of infection and/or placed the patients at risk of fire. The failed practice had the likelihood to affect all patients, staff and visitors, Findings follow:

A. Observation of the kitchen on 1/14/2025 at 12:48 PM showed the following:
1) Wall penetration in the middle of ceiling that was not sealed by fire resistant caulk.
2) Ceiling tiles throughout dietary needed to be changed due to being cracked and stained.
3) Vents needed cleaning in dietary contained dust and debris.

B. The findings of A were verified with the Director of Plant Operations on 1/14/24 at 3:15 PM

C. Observation of the Emergency Department on 1/13/2025 at 1:30 PM showed the following:
1) Damaged cabinet doors in break room were hanging off hinges and it needed cleaning under the sink.
2) Floor needed to be repaired and cleaned in the break room.
3) Ceiling tiles were damaged in main entrance of Emergency Department in that they were cracked and stained.
4) Emergency receptacles were not labeled to show they had properly been checked yearly (NFPA requirements for polarity and tension testing on emergency receptacles, as specified in NFPA 70 (National Electrical Code) and NFPA 99 (Health Care Facilities Code), mandate that emergency receptacles must be tested to ensure correct polarity and proper tension, ensuring they function reliably during an emergency to provide power for critical equipment)).
5) Fire double doors leading into Emergency Department did not latch completely (NFPA requirements for fire door latching, as outlined in NFPA 80 (Standard for Fire Doors and Other Opening Protectives), specify that fire doors must be equipped with a latching mechanism that ensures the door remains securely closed under normal conditions, and the latch must be capable of holding the door closed during a fire, preventing the spread of smoke and flames)).

D. The finding of C were verified with the Director of Plant Operations on 1/14/25 at 3:00 PM.