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Based on observations, review of facility documents, review of facility policies and procedures, and interviews with staff facility failed to ensure all plumbing fixtures be maintained in good repair to assure proper functioning.

Findings:

Observations on 05/08/2023 at 3:12 p.m. and again on 05/11/2023 at 11:49 a.m. of Unit 3 South noted an eye wash station located in the hall near the nursing station had a sign in the sink that read "out of order". This was also observed and acknowledged by the Chief Nursing Officer and Education Director who accompanied surveyor to the unit on 05/08/2023. Interview with the Plant Operations Director on 05/11/2023 at 10:34 a.m. where he stated in the Hospital's risk assessment it had been determined the eye wash station was not needed in that area as they no longer used any caustic/corrosive materials. Continued interview with him found he had a plumber who had brought the non-operational station to his attention, but not sure of exactly when. Review of the "Plumbed Eyewash/Drench Hose Weekly Inspection Form" presented by Plant Operations Director as requested, documented the station had been assessed as out of order at least since 03/20/2023 and as of time of observation on tour and interview with him, the station had not been repaired. When asked for the work order (W0092940) that was generated for the station's repair, the generation date of the request reflected 01/23/2023 at 02:28 p.m. with a completion date of 02/24/2023, with requester comment noting "Eye wash test done weekly has to run for a minimum of 3 minutes. The sink fills and overflows long before the 3 minute time is up." Continued interview with Plant Operations Director noted the sink/plumbing problems now had an expected date to be completed within 2 weeks of this past Monday (05/08/2023).

Review of facility's policies & procedures "iCREF Work Order Process Chapter: Environment of Care Policy number: EOC 09 Origination date: 08/09/2022" noted the facility failed to ensure "Preventative Maintenance (PM)" which facility defined to be: "The act of performing regularly scheduled maintenance activities to help prevent unexpected failures in the future. Maintenance that is proactively performed on an asset with the goal of lessening the likelihood of failure, reducing unexpected downtime, and prolonging its useful life.