Every finding on record at Hh Health System - Caring for Life, LLC

Based on review of medical records (MR), agency policy and procedure, and interview it was determined the agency failed to ensure an Initial Bereavement Risk Assessment was completed for each patient and family. This affected eight of 26 MRs reviewed, including Home Visit (HV) # 5, MR # 5, MR # 6 MR # 8, MR # 11, MR # 19, HV # 1, HV # 6, and had the potential to negatively affect all patients and families served by the hospice agency.Findings include:Agency Policy: Initial Bereavement AssessmentPolicy Number: 9012Date Revised: 10/31/21Purpose:To provide guidelines for the assessment and reassessment of the bereavement needs of families or caregivers.Policy:...Information obtained from the initial bereavement assessment shall be incorporated into the plan of care and in the bereavement plan of care.Procedure:On admission, the hospice social worker or spiritual counselor shall complete a Bereavement Risk Assessment. --- Review of the initial assessments completed by the social worker and the chaplain revealed no documentation of an initial bereavement risk assessments for HV # 5, MR # 5, MR # 6 MR # 8, MR # 11, MR # 19, HV # 1, HV # 6, per the agency's policy.An interview was conducted on 10/9/25 at 5:30 PM with Employee Identifier  # 1, Director of Operations, who confirmed there was no documentation the initial bereavement risk assessment was obtained and incorporated into the bereavement plan of care for patients and families per the agency's policy.

Based on review of medical records (MR), agency policy and procedure, and staff interviews, it was determined the agency failed to ensure staff obtained a return demonstration from the patient/caregiver (pt/cg) for wound care and blood glucose monitoring, per the physician's order.This affected MR # 16 in one of one MRs reviewed with orders for pt/cg education and return demonstration for wound care and obtaining the blood glucose level.Findings include: Agency Policy: Patient Education ProcessPolicy Number:9201Date Revised: 10/31/21Policy:The assessed needs of pt, family, cg will determine the scope of teaching and the medical plan of care.Procedure:...Unless specifically ordered by a physician, the pt, family, or cg shall receive verbal, and when appropriate written instructions, when indicated in:...Prescribed treatments, ...Safe and effective use of equipment and supplies......Documentation of pt, family, cg education shall consist of:Describing patient teaching...describing patient's response to teaching...The hospice shall assess the pt, family, cg's knowledge, skills, and behaviors during the home visit....provide re-education as needed. --- 1. MR # 16 was admitted to the agency on 6/26/25 with a primary diagnosis of Sarcopenia.Review of the Physician's Orders/Plan of Care dated 6/26/25 to 9/23/25 revealed the following orders:Skilled Nurse (SN) to teach pathophysiology, care, and treatment of stage two sacral pressure ulcer dated 6/26/25. Wound care to be provided to stage two sacral pressure ulcer as follows: cleanse site with wound cleanser, gently pat dry with gauze. Cover wound with adhesive bordered foam dressing. Dressing to be changed every seven days or as needed if soiled/dislodged. SN to perform wound care during visits, family to provide at all other times after adequate education and return demonstration.SN order dated 6/26/25-Fingerstick blood sugar (FSBS) checks as needed for signs/symptoms of hyperglycemia or hypoglycemia. To be performed by SN or pt/cg after adequate return demonstration.Review of the SN Initial Visit Note dated 6/26/25 and SN Routine Visit Note dated 7/2/25 revealed no documentation of a return demonstration from the pt/cg for wound care or FSBS monitoring.An interview was conducted on 10/9/25 at 4:36 PM with EI # 1, Director of Operations, who confirmed staff failed to ensure a return demonstration was obtained for wound care and blood glucose monitoring, per the physician's order.

Based on review of medical records (MR) and staff interviews, it was determined the agency failed to ensure staff provided wound care per the physician's orders.This affected three of eight MRs reviewed with wound care ordered, including MR # 20, MR # 16, and Home Visit (HV) # 6, and had the potential to negatively affect all patients served by the agency. Findings include: --- 3. HV # 6 was admitted to hospice services on 7/8/25 with a primary diagnosis of Senile Degeneration of Brain, Not Elsewhere Classified.Review of Supplemental Orders dated 7/29/25 revealed care and treatment orders for a third degree burn to the left lateral ankle as follows:Cleanse site with wound cleanser, gently pat dry with gauze.  Apply Hydrofiber Ag (Aguacel Ag) to wound bed to decrease microbial load, assist with debridement, promote healing and assist with excessive draining.  Cover with bordered foam dressing.  Dressing to be changed every other day or prn (as needed) if soiled/dislodged.  SN to perform wound care during visits, family to provide at all other times after adequate education and return demonstration.Review of 14 routine SN visit notes from 7/31/25 to 9/18 25 revealed the SN documented the following:Dressing Changed this Visit: “Yes, per orders, see Care Plan.”  There was no documentation of the treatment performed. An interview was conducted on 10/9/25 at 5:00 PM with EI # 1 who confirmed the SN failed to document the wound care provided per hospice policy and procedure. 2. MR # 16 was admitted to the agency on 6/26/25 with a primary diagnosis of Sarcopenia.Review of the Physician's Orders/Plan of Care from 6/26/25 to 9/23/25 revealed orders for Wound Care to be provided by the Skilled Nurse (SN) to Stage 2 sacral pressure ulcer as follows:Cleanse site with wound cleanser, gently pat dry with gauze. Cover wound with adhesive bordered foam dressing. Dressing to be changed every seven days or as needed if soiled or dislodged. SN to perform wound care during visits, family to provide at all other times after adequate education and return demonstration.Review of the SN Visit Note (VN) dated 6/26/25 revealed the SN failed to document the wound care provided.Review of the SN VN dated 6/27/25 revealed the SN documented the dressing was not changed.An interview was conducted on 10/9/25 at 4:36 PM with EI # 1, who confirmed staff failed to perform wound care per the physician's order. 1. MR # 20 was admitted to the hospice on 9/24/25 with a primary diagnosis of Sarcopenia.Review of the physician's wound care orders dated 9/24/25 revealed for the Skilled Nurse (SN) to provide wound care as follows to the Stage II Pressure Ulcer to right hip, Skin Tear to right shin, Trauma wound to right leg, Skin Tear to right lower leg:Remove old dressing. Cleanse site with soap and water, pat dry with gauze, apply bordered gauze, or adhesive dressing. Dressing to be changed every five days and when soiled or dislodged.Review of the On call/ Unscheduled visit notes dated 9/29/25 and 9/30/25 revealed no documentation the SN provided wound care every five days per the physician's orders.An interview was conducted on 10/9/25 at 5:31 PM with Employee Identifier (EI) # 1, Director of Operations, who confirmed the SN failed to provide wound care per the physician's orders.

Based on review of medical records (MR), hospice policy, and staff interviews it was determined the agency failed to ensure the hospice aide (HA) notified the Registered Nurse (RN) with changes in the patient’s condition or need for changes in the Plan of Care (POC). This deficiency was identified on the prior recertification survey dated 2/2/23.This affected three of 21 MRs reviewed with aide services ordered, including MR # 8, MR # 12, and MR # 14, and had the potential to negatively affect all patients served by the agency.Findings include:Hospice Policy: Hospice Aide ServicesPolicy Number: 9107Revised: 10/31/21Purpose: To specify the role of the Hospice Aide. Policy: Hospice Aide services shall include personal care and non-skilled services provided by the trained Hospice Aides. …The core skills include: Monitoring pain and symptom management and reporting to the RN…Routine care shall include Hospice Aide services for personal care as needed. Hospice Aide shall provide services such as giving a bath… --- 3. MR # 14 was admitted to the in patient hospice on 10/3/25 with primary diagnosis of Second Malignant Neoplasm of Unspecified site. Review of the Hospice POC with start of care date 10/3/25 revealed orders for Aide frequency visits for one visit times one week.Review of the Change Aide Care Plan Order dated 10/7/25 revealed orders for Aide to perform a bed bath every other day and prn (as needed).Review of six Aide Regular Visits dated 10/3/25 to 10/8/25 revealed no bed bath was performed and no documentation the RN was notified. An interview was conducted on 10/9/25 at 4:40 PM with EI # 1, who confirmed the HA failed to notify the RN the interventions were not completed which required a change to the patient's POC. 1. MR # 8 was admitted to the agency on 9/5/25 with a primary diagnosis of Cerebrovascular Disease.Review of the Hospice POC for Certification Period 8/31/25 to 10/29/25 revealed orders for HA visits once weekly for one week, then twice weekly for four weeks.Review of the Team Care Plans dated 9/3/25, 9/16/25, and 9/30/25 revealed HA Interventions as follows:Incontinence/diapers, Complete bed bath, hair care, notify RN if no bowel movement (BM) in 3 days or hasn't voided in 12 hours, oral hygiene/mouth swab every visit and shave patient and change bedding per caregiver request.Review of the Visit Record (VR) dated 9/3/25 revealed the HA documented the complete bed bath, shaving, bedding change, and oral hygiene were not completed.Review of the VR dated 9/8/25 revealed the HA documented the complete bed bath, shaving, assist with dressing, and bedding change were not completed.Review of the VR dated 9/10/25 revealed the HA documented the complete bed bath, shaving, and bedding change were not completed.Review of the VR dated 9/15/25 revealed the HA documented the complete bed bath, notify RN if no BM in 3 days or hasn't voided in 12 hours, and bedding change were not completed.Review of the VR dated 9/17/25 revealed the HA documented the complete bed bath, shaving, and bedding change were not completed.Review of the VR dated 9/24/25 revealed the HA documented the incontinence/diapers and shaving were not complete.Review of the VR dated 9/29/25 revealed the HA documented the complete bed bath, shaving, assist with dressing, and bedding change were not completed.There was no documentation the HA notified the RN the interventions were not completed, which required a change to the POC.An interview was conducted on 10/9/25 at 4:34 PM with Employee Identifier (EI) # 1, Director of Operations, who confirmed the HA failed to notify the RN the interventions were not completed, which required a change in the patient's POC.2. MR # 12 was admitted to the agency on 9/7/25 with a primary diagnosis of Malignant Neoplasm of Unspecified Ovary.Review of the Hospice POC for Certification Period 9/7/25 to 12/5/25 revealed orders for HA visits once weekly for one week, then twice weekly for nine weeks.Review of the Team Care Plans dated 9/16/25, 9/30/25, and 10/7/25 revealed the following HA Interventions were added to the Care Plan on 9/2/25:Shower, Assist with dressing, Notify RN if no BM for 3 days or hasn't voided in 12 hours, Incontinent/Diapers, Change bedding,Review of the Aide Care Plan dated 10/1/25 to Current revealed HA tasks as follows:Apply deodorant, Apply lotion to all extremities, Assist with dressing, Brush teeth with toothbrush and toothpaste, change linens, clean finger nails, Comb or brush hair, Document last BM, Perineal Care, Shower, all to be done every visit, and Wash hair weekly and as needed at patient or caregiver request.Review of the VRs dated 9/7/25, 9/11/25, and 9/16/25 revealed the HA documented the bedding change was not completed.Review of the VRs dated 9/18/25, 9/23/25, 9/25/25, and  9/30/25 revealed the HA documented the shower and bedding change were not completed.Review of the Aide Regular Visit on 10/2/25 revealed the HA documented the patient refused the bedding change.There was no documentation the HA notified the RN of interventions that were not completed, which required a change in the POC.An interview was conducted on 10/9/25 at 4:35 PM with EI # 1, who confirmed the HA failed to notify the RN of interventions that were not completed, which required a change in the patient's POC.

Based on review of medical records (MR), hospice policies and procedures, and staff interview, it was determined the hospice nurse failed to document the disposal of all medications per the hospice policies and procedures. This affected one of three death records, including MR # 17,  and had the potential to negatively impact all patients.Findings include:Hospice Policy: Death at HomePolicy Number: 9118Revised: 10/31/21Purpose:To establish the process to follow when a patient dies at home while receiving care from hospice...Procedure:…The hospice skilled nurse (SN) shall instruct the family how to dispose of all medications, including controlled substances, per local and state regulations. The SN documents the medications disposed in the clinical record.Hospice Policy: Controlled Drug Disposal In The HomePolicy Number: 7012Revised: 10/31/21Policy:… The staff member that oversees the disposal of the controlled drugs will document the following in the clinical record:1.     Name of drug2.      Amount disposed3.      Method of disposal4.      Name of the person destroying the medication(s)5.      Name of the staff witness6.      … Date and time --- MR # 17 was admitted to the hospice on 9/1/24 with primary diagnosis of Malignant Neoplasm of Vulva Unspecified.Review of the On-call/Unscheduled (Death) visit dated 10/16/24 revealed no documentation of the method of disposal, name of the person destroying the medication(s), name of witness, and date and time the controlled drugs were disposed. An interview was conducted on 10/9/25 at 4:43 PM with Employee Identifier # 1, Director of Operations, who confirmed the nurse failed to document the disposal of medications per the agency policy.

Based on review of Medical Records (MR), agency policy and procedure, and interviews, it was determined the agency failed to ensure the Plan of Care (POC) ordered frequencies were followed for all disciplines. This deficient practice affected 3 of 16 MR reviewed including MR # 6, Home Visit (HV) # 2, and MR # 1 and had the potential to affect all patients admitted to this hospice. Findings include: Agency Policy: Changes in Care, Treatment, and Services - Patient Notification Reference Number: 9113 Revised: 10/31/2021 Purpose: To define the requirements for patient notification of changes in care, treatment, and services. Policy: Hospice staff shall give the patient, family or caregiver immediate notice (no more than 24 hours), of significant changes in the agreed-upon schedule or plan of care. Procedure (Visit Schedule): When Hospice staff cannot make a visit because of unforeseen problems, the patient, family, or caregiver is contacted to jointly reschedule the visit. --- 2. HV # 2 was admitted to hospice on 11/9/22 and recertified for hospice care from 1/8/23 to 3/8/23 with diagnoses including Alzheimers Disease Unspecified and Sepsis, Unspecified Organism. Review of the Care Plan for certification period beginning 1/8/23 revealed orders for the Skilled Nurse (SN) two times a week for eight weeks, effective 1/9/23. Review of the SN visit notes for week of 1/22/23 revealed only one SN note dated 1/25/23 and not two SN notes as ordered. Further review of the MR revealed no documentation of a missed visit for the week of 1/22/23. An interview conducted on 2/2/23 at 3:54 PM with EI # 1, Registered Nurse (RN), Outpatient Manager (OPM), confirmed the staff failed to follow the physicians SN order frequency per the agencys policy. 3. MR # 1 was admitted to hospice on 1/5/23 and certified for hospice care from 1/5/23 to 4/4/23 with diagnosis including Unspecified Protein-Calorie Malnutrition. Review of the Care Plan for certification period beginning 1/5/23 revealed Hospice Aide visit orders effective 1/5/23 one time a week for one week, and 1/9/23 two times a week for eleven weeks. Review of the HA visit notes for week of 1/15/23 revealed only one aide note dated 1/18/23 and not two HA notes as ordered. Further review of the MR revealed no documentation of a missed visit for the week of 1/15/23. An interview conducted on 2/2/23 at 3:37 PM with EI # 1, RN, OPM, confirmed the staff failed to follow the HA ordered frequency per the agencys policy. 1. MR # 6 was admitted to the agency on 7/13/22, with current recertification period of 1/9/23 - 3/9/23, with diagnoses including Encephalopathy, Unspecified, and Chronic Respiratory Failure, Unspecified Whether With Hypoxia or Hypercapnea. Review of the Medical Record (MR) for certification period beginning 1/9/23, revealed orders for Hospice Aide (HA) visits twice weekly for nine weeks. Review of the visit note reports for the aide revealed one visit the week of January 15-21 and not two visits as ordered on the plan of care. There was no documentation of a missed visit and no documentation of attempts to reschedule the visit. In an interview conducted on 2/2/23 at 3:29 PM, Employee Identifier (EI) # 3, Director of Nursing, confirmed the visit frequency was not followed as ordered for the HA.

Based on observations, agency policies and procedure, Centers for Disease Control (CDC) hand hygiene in health care settings guidelines, CDC safe injection practices, and interview, it was determined the agency failed to ensure all staff performed effective hand hygiene. This deficient practice affected two of three observations of hand hygiene, and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Hand Hygiene - CDC Guidelines Policy Number: 4006 Revision Date: 10/31/21 Purpose: To provide guidelines for effective hand hygiene, in order to prevent the transmission of bacteria, germs, and infections. Policy: All staff shall use the hand hygiene techniques as set forth in the following procedure... ...Before each patient encounter Procedure: Using ...soap and water...Rinse hands...Dry hands with clean disposable paper towel, Turn off faucets with used paper towel and discard. Agency Policy: Food and Nutrition Services Infection Control Policy Policy Number: IC.004.05 Review/Revision Date: June 2016 Policy: Employees: ...Effective hand washing/sanitizing techniques are taught. Hand washing/sanitizing is required of all employees: 1. Before beginning work. ...7. Between handling of cooked and uncooked foods. CDC Hand Hygiene in Healthcare Settings:January 2020 The Core Infection Prevention and Control Practices for Safe Care Delivery in all Healthcare Settings recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) include the following strong recommendations for hand hygiene in healthcare settings. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: a. Immediately before touching a patient... March 2, 2011 CDC Injection Safety Information for Providers FAQs (Frequently Asked Questions) Regarding Safe Practices for Medical Injections: FAQs Regarding Safe Practices for Medical Injections: Medication Preparation Questions: How should I draw up medications? Parenteral medications should be accessed in an aseptic manner... Proper hand hygiene should be performed before handling medications.. --- 1. An observation of medication administration to an unsampled patient by Employee Identifier (EI) # 8, Registered Nurse (RN) was conducted on 1/31/23 at 2:55 PM. EI # 8 entered the facility medication room, obtained two single dose medication vials of Robinul 0.4 milligrams (mg) per 2 milliliter (ml) injection solution from the Pyxis (secure electronic unit that stores medications), and drew up the medication utilizing a syringe and needle without performing hand hygiene. EI # 8 then entered the unsampled patient's room and administered the medication via a subcutaneous access port without performing hand hygiene prior to administration. After administering the medication, EI # 8 washed his/her hands at the patient room sink with soap and water, and turned the faucet off with his/her bare hands before drying with a paper towel. EI # 8 failed to follow agency policy and procedure and CDC guidelines to perform hand hygiene prior to handling the medications and encountering the patient, and failed to utilize a paper towel to turn the water faucet off. An interview conducted on 2/2/23 at 5:00 PM with EI # 2, Inpatient Manager confirmed EI # 8 did not perform hand hygiene per agency policy and the CDC standards for safe injection practices. 2. An observation of lunchtime meal preparation by EI # 5, Facility Care Tech, was conducted on 2/1/23 at 11:47 AM. EI # 5 washed his/her hands with soap and water prior to beginning meal preparation, and turned the faucet off with his/her bare hands before drying with a paper towel. EI # 5 did not follow agency procedure when washing his/her hands to utilize the paper towel to turn off the faucet. An interview conducted on 2/2/23 at 5:00 PM with EI # 2, Inpatient Manager confirmed EI # 5 did not perform hand hygiene per agency policy.

Based on review of medical records (MR), agency policy and procedure, Alabama Board of Nursing Administrative Code, agency on-call log, and interviews, it was determined the agency failed to ensure: The Registered Nurse (RN) evaluated and assessed the need for a Skilled Nurse (SN) visit for calls received from patients after the agency office was closed. The RN obtained the death pronouncement from the physician as directed by the Alabama Board of Nursing. This deficient practice affected one of fifteen on-call entries reviewed, and one of two death records reviewed, and had the potential to negatively affect all patients served by the agency. Findings include: Alabama Board of Nursing Administrative Code Standards of Nursing Practice Section: 610-X-6-.05 Practice of Practical Nursing (Licensed Practical Nurse Practice). Reviewed: 12/30/22 (1) The practice of practical nursing includes the performance, for compensation, of acts designed to promote and maintain health, prevent illness and injury, and provide care utilizing standardized procedures and the nursing process, including administering medications and treatments, under the direction of a licensed professional nurse or a licensed or otherwise legally authorized physician or dentist. Such practice requires basic knowledge of the biological, physical, and behavioral sciences and of nursing skills but does not require the substantial specialized skill, independent judgment, and knowledge required in the practice of professional nursing. Alabama Board of Nursing Administrative Code Standards of Nursing Practice Section: 610-X-6-.09 Standards for Patient Assessment Reviewed: 1/31/23 (1) Patient assessment shall be provided in accordance with the definitions of professional nursing and practical nursing, as defined in the Alabama Nurse Practice Act. The licensed practical nurse practicing under the supervision of an RN...or other authorized health care provider shall deliver and participate in nursing care, to include: (a) Completing independent or comprehensive patient assessments of the health status of the patient under approved standardized procedures. Alabama Board of Nursing Standards of Nursing Practice 610-X-.15 Telecommunication For Pronouncement of Death (1) The licensed nurse may receive pronouncement of a patient's death from a physician via telecommunications without a physical examination of the patient by that physician. (2) The facility policy shall specify the permissible patient conditions for which the licensed nurse in a specific health care facility or agency may receive the pronouncement of a patient's death by telecommunication. Agency Policy: On-Call Services Policy Number: 9108 Review Date: 10/31/21 Purpose: To establish the process for patients to access Hospice services any time. Policy: Hospice shall provide on-call coverage anytime the business is closed...The SN responds to the call and, when needed, provides a home visit. On-Call Guidelines: It is not an exhaustive list, but includes many problems that may require a visit... Death or suspected death, ... uncontrolled pain, ...new onset seizures...respiratory difficulty Procedure: ...The Hospice on-call SN shall provide appropriate follow-up...visit the patient, if necessary... --- 2. MR # 9 was admitted to the agency's inpatient unit on 1/17/23 with diagnoses including Encephalopathy Unspecified, and Acute Respiratory Failure, Unspecified Whether With Hypoxia or Hypercapnea. Review of the 1/20/23 Death Visit Note revealed the SN documented, "Respirations have ceased, no palpable pulse, dilation and fixation of pupils. Death, pronounced by (name) RN (EI # 7). Time of death 2:07 AM." There was no documentation EI # 7 notified the physician of the absence of vital signs and received the pronouncement of death from the physician via telecommunication. An interview conducted on 2/2/23 at 3:27 PM with EI # 2, RN Inpatient Manger, confirmed there was no documentation the physician made the pronouncement of death. 1. Review of the hospice agencys on-call log indicated Employee Identifier (EI) # 6, License Practical Nurse (LPN) received call when the agency was closed on 1/16/23 at 6:30 AM. Review of clinical note dated 1/16/23 revealed EI # 6 LPN made a SN visit. Further review of clinical note dated 1/16/23 revealed no documentation of RN notification or communication with EI # 6 for the need of a SN visit. In an interview on 2/2/23 at 3:17 PM with EI # 1, RN, Outpatient Manager (OPM), verified the LPN received calls and independently determined the need of a patient SN visit, without the direction of a RN, as defined in the Alabama Nurse Practice Act. EI # 1, RN, OPM confirmed the agency failed to ensure a RN evaluated and assessed the need for a SN visit for calls received from patients when the agency was closed.

Based on medical record (MR) review, agency policy and procedure, and staff interviews, it was determined the hospice failed to ensure the Hospice Aide (HA) notified the Registered Nurse (RN) regarding tasks not completed per ordered Plan of Care (POC). This affected 1 of 16 MR reviewed, including MR # 6, and had the potential to negatively affect all patients with HA services. Agency Policy: Hospice Aide Assignments and Duties Reference Number: 3103 Revised: 10/1/21 Policy: ...The POC shall indicate what tasks are to be done by the HA and the frequency of the tasks... Procedure: ...HAs shall report changes in the patient's medical, nursing, rehabilitative and social needs to a RN as the changes relate to the POC and Performance Improvement (PI) activities. --- 1. MR # 6 was admitted to the agency on 7/13/22 with diagnoses including, Encephalopathy, Unspecified, and Chronic Respiratory Failure, Unspecified Whether with Hypoxia or Hypercapnea and recertified for hospice services 1/9/23-3/9/23. Review of the plan of care effective 1/9/23 revealed HA services were ordered twice weekly for nine weeks with the following assigned task from the RN: Bed Bath Complete Review of the aide visit note reports dated 1/10, 1/19, and 1/26 revealed the HA failed to complete a bed bath as assigned. There was no documentation the HA notified the RN that the bed baths were not completed, and no documentation by the HA to explain why they were not completed. An interview was conducted on 2/2/23 at 3:29 PM with Employee Identifier (EI) # 3, Director of Nursing, who confirmed that the HA failed to follow the Aide Plan of Care and failed to notify the RN of tasks not completed as ordered.

Based on observations, review of dietary logs, facility policy, US Food and Drug Administration (FDA) Food Code, and interviews, it was determined the Inpatient Unit (IPU) failed to ensure the dietary staff: 1. Stored and labeled food safely and correctly. 2. Documented cleaning of the ice machine, refrigerator, and freezer. This had the potential to negatively affect all patients. Findings include: Agency Policy: Food and Supply Storage Procedures Policy Number: 13005 Revision Date: 10/31/21 Refrigerated Storage: ...Date and rotate items ...Unused Portions: cover, label, date and store... FDA Food Code 2022 Chapter 4 Equipment, Utensils, and Linens (5) EQUIPMENT is used for storage of PACKAGED or unPACKAGED FOOD such as a reach-in refrigerator and the EQUIPMENT is cleaned at a frequency necessary to preclude accumulation of soil residues; (6) The cleaning schedule is APPROVED based on consideration of: (a) Characteristics of the equipment and its use, (b) The type of food involved, (c) The amount of food residue accumulation, and (d) The temperature at which the food is maintained during the operation and the potential for the rapid and progressive multiplication of pathogenic or toxigenic microorganisms that are capable of causing foodborne disease... --- 1. A tour of the Inpatient Dietary Department was conducted on 2/1/23 at 11:47 AM with Employee Identifier (EI) # 5, Facility Care Tech. Inside the refrigerator there was observed an opened nine ounce container of smoked ham lunch meat. There was no label with the date the ham was opened. During the tour, the surveyor asked EI # 5 when the ice machine, refrigerator and freezer were routinely cleaned. EI # 5 referred to a Master Cleaning Schedule posted on the wall which outlined cleaning tasks by days of the week. Review of the schedule revealed the freezer was to be cleaned every Monday, refrigerator every Tuesday, the ice machine on the third Sunday of each month. EI # 5 confirmed during the dietary tour there was no documentation of the cleaning tasks being performed as scheduled. An interview conducted on 2/2/23 at 5:00 PM with EI # 2, Inpatient Facility Manager confirmed the ham luncheon meat was not stored per policy, and there was no documentation of kitchen equipment cleaning.

Based on observation, the facility failed to limit the storage of Alcohol Based Hand Rub (ABHR) solution per the requirements of: 2012 NFPA 101, 19.3.2.6 (7) This deficiency affects 1 of 2 smoke compartments. --- Findings include: On 01/31/2023, during a tour of the facility from 1:00 pm to 4:00 pm, the surveyor observed 6.96 gallons of ABHR solution stored in the Janitors Room (one smoke compartment) located across the corridor from the Children's Play area. A member of maintenance staff was present when this deficiency was identified. .

Based on review of documentation, the facility failed to maintain the automatic sprinkler system riser gauges per the requirements of: 2012 NFPA 101, 19.3.5.1, and 9.7.5 2011 NFPA 25, 5.3.2.1 This deficiency affects 2 of 2 smoke compartments. --- Findings include: On 01/31/2023, during a tour of the facility from 1:00 pm to 4:00 pm, the surveyor observed that the automatic sprinkler system wet riser gauges had not been calibrated or replaced within the past 5 years. The gauges were installed in 2017 per interview and documentation. A member of the maintenance staff was present when this deficiency was identified. .

Based on observation, the facility failed to maintain corridor doors per the requirements of: 2012 NFPA 101, 19.3.6.3.5 42 CFR 483.90 (a) (1) (ii) S&C-07-18 This deficiency affects 1 of 2 smoke compartments. --- Findings include: On 02/01/2023, during a tour of the facility from 8:00 am to 10:30 am, the surveyor observed the following: 1. Patient Room 113's corridor door failed to close and latch 2. Patient Room 109's corridor door had a 5/8 inch gap between the door and door frame when the door was closed and latched A member of the maintenance staff was present when this deficiency was identified.