Dewitt Hospital & Nursing Home, Inc.

“Eligibility and process for appointment CFR(s): (a)(1) The medical staff must periodically conduct appraisals of its members. This Standard is not met as evidenced by: 31039 Based on review of Rules and Regulations for Hospitals and Related Institutions in Arkansas, review of Physician Credentialing files and interview, it was determined the facility failed to follow State Regulations in that they failed to evaluate the Physician members’ professional activities (also referred to as peer review) at the time of reappointment for five of five (#1, #2, #3, #4, and #5) Physicians. By not reviewing the Physician members’ professional activities, the facility could not assure that physicians were competent and practiced within the boundaries of professionally accepted norms, which improves the quality and safety of the health care provided. The failed practice had the likelihood to affect all patients that were treated at the hospital. Findings follow: A. Review of the Rules for Hospitals and Related Institutions in Arkansas, Section 6. MEDICAL STAFF, A.9. Showed an individual file shall be maintained for each physician practicing in the hospital and shall include an evaluation of members’ professional activities at the time of reappointment. B. Review of Physician Credentialing files showed Physicians #1, #2, #3, #4, and #5 did not have an evaluation of members’ professional activities at the time of reappointment. C. During an interview on 01/28/2025 at 1:00 PM, the Director of Medical Records verified the Facility failed to evaluate the above mentioned five Physician members’ professional activities at the time of reappointment.”

“Pharmacy management and administration. CFR(s): (a)The pharmacy or drug storage area must be administered in accordance with accepted professional principles and in accordance with state and Federal laws. This Standard is not met as evidenced by: 31039 Based on review of manufacturers’ recommendations, observation and interview, it was determined the facility failed to adhere to accepted professional standards in that they did not follow manufacturer’s recommendations for storage of IV (Intravenous) solutions in two of two (Emergency Room and Radiology) fluid warmers. By not following manufacturer’s recommendations for storage, the facility could not assure the safety and efficacy of the solutions available for patient use. The failed practice had the likelihood to affect all patients that have had procedures in the facility that required IV fluids in these departments. Findings follow: A. Review of Manufacturer’s storage recommendations for Baxter Sodium Chloride IV solutions showed they should be stored at room temperature. The product could be briefly exposed up to 40 degrees Celsius (104 degrees Fahrenheit) but does not mention storing at this temperature. B. During a tour of the Emergency Department on 01/27/2025 from 11:55 AM to 1:15 PM, observation showed three 500 ml (milliliter) Sodium Chloride IV solutions, and three 1000 ml Sodium Chloride IV solutions stored in a warmer set at 100 degrees Fahrenheit. C. During a tour of the Radiology Department on 01/28/2025 from 9:00 AM to 9:30 AM, observation showed ten 50 ml Sodium Chloride IV solutions stored in a warmer set at 35 degrees Celsius (95 degrees Fahrenheit). D. During an interview on 01/27/2025 at 12:54 PM, the Director of Nursing verified the findings at B. E. During an interview on 01/28/2025 at 9:00 AM, the Director of Radiology verified the findings at C.”

“Administration of drugs. CFR(s): (c)Drugs must be prepared and administered according to established policies and acceptable standards of practice. This Standard is not met as evidenced by: 31039 Based on review of facility policy, review of United Stated Pharmacopeia (USP) 797 regulations, review of nurse competencies and interview, it was determined the facility failed to establish policies and follow acceptable standards of practice in that they did not have policies for training and assuring competencies in Compounding Sterile Products (CSP) for immediate use for 13 of 13 (#1-#13) Registered Nurses (RN) and 5 of 5 (#1-#5) Licensed Practical Nurses (LPN) who make or have the potential to make CSPs for immediate use. By not assuring the nurses are trained and competent, the facility could not assure the products delivered intravenously (IV) were free from inadvertent microbial contamination. The failed practice had the likelihood to affect all patients who receive immediate use CSP in the facility. Findings follow: A. Record review of the facility’s policy titled “Intravenous Admixture Service,” showed all intravenous admixtures will be prepared by nursing for immediate use according to USP 797 Regulations. The policy also showed those regulations were attached to the policy but were not. B. Record review of United Stated Pharmacopeia (USP) 797 regulations showed personnel were to be trained and demonstrate competency in aseptic processes as they related to assigned tasks and the facility’s Standard Operating Procedures (SOP). C. Record review of nurses’ competencies for 2024 did not have any training or competency requirements evaluated for 13 of 13 (#1-#13) Registered Nurses (RN) and 5 of 5 (#1-#5) Licensed Practical Nurses (LPN) who make or have the potential to make CSPs for immediate use. D. During an interview on 01/28/2025 at 7:55 AM, the Director of Pharmacy verified the facility failed to establish policies and follow acceptable standards of practice in that they did not have policies for training and assuring competencies in Compounding Sterile Products (CSP) for the nurses who make or have the potential to make CSPs for immediate use. E. During an interview on 01/28/25 at 9:08 AM, The Director of Nurses verified the facility failed to establish policies and follow acceptable standards of practice in that they did not have policies for training and assuring competencies in Compounding Sterile Products (CSP) for the nurses who make or have the potential to make CSPs for immediate use.”

“Infect prevent & control program org & policy CFR(s): (a)(3) The infection prevention and control program include surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 31039 Based on review of policy, observation, and interview, it was determined the facility failed to maintain the sinks in the medication preparation areas clean and sanitary, per policy, in two of two (Observation and Emergency) Departments toured. By not keeping the sinks in 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 of affecting all patients receiving medications from these patient care areas. Findings follow: A. Record review of the facility’s policy titled, “Pharmacy: Infection Control” showed the sinks should be cleaned daily with an approved antiseptic solution. B. During a tour of the facility on 01/27/2025 from 11:55 AM to 1:15 PM, observation showed the following: 1) Observation Department - Medication Room hand washing sink was dirty. There was a thick brown chunky accumulation around the drain, and into the rings going down the drain. A paper towel was used to wipe the accumulation, and chunks of the brown substance were easily wiped up and cling to the paper towel. 2) Emergency Room Department - Medication Room hand washing sink was dirty. There was an accumulation of a light brown substance around the drain. There were 3 blue tubs sitting in the sink along with a pen and a vial top. A paper towel was used to wipe the accumulation, and the brown substance was wiped up and visible on the paper towel. C. During an interview on 01/27/2025 at 12:10 PM, Medication Nurse #1 verified the findings at B.1. D. During an interview on 01/27/2025 at 12:49, The Director of Nursing verified the findings at B.2. 46733 Based on policy and procedure review, job description review, observation and interview, the Dietary Manager and Production Supervisor failed to ensure that thermometers were calibrated prior to testing food temperature at each meal in one of one kitchen. The failed practice did not ensure food temperatures were accurately obtained and documented prior to being served to patients, visitors and staff members, which did not ensure food safety/sanitation to avoid sources and transmission of infection and had the likelihood of affecting anyone served meals from the kitchen. Findings follow: A. Review of policy and procedure titled, “Thermometer Calibration” showed, “Policy-Temperatures of food shall be monitored using accurate thermometer. Thermometers should be accurate to 2 degrees Fahrenheit. Procedure-1. Use the “ice proof” method (considered the most accurate {to 0.1 F}) method for calibration. A. Fill Styrofoam cup 5” (inches) or deeper with ice. B. Add water to fill the cup. C. Allow water temperature to stabilize at 21 F (4-5 minutes) D. Insert thermometer. Keep at least one inch from bottom and sides of cup. E. Let temperature reading on thermometer come down to 32 F (about 1 minute). F. Adjust the needle by turning the nut with a 7/16” wrench to exactly (close one eye and look directly about the 33 degrees mark). Calibration date recorded on “Pot and Pan Sheet”. Thermometers are cleaned and sanitized according to pot and pan procedures or run through dishwasher machine.” B. Review of the Dietary Managers Job Description showed, “A. Function: Plans, organizes, and controls the activities of the food service department to provide food services as prescribed by professional standards.” C. Review of the Production Supervisors Job Description showed, “B. 6. Supervises tray service, checks trays at mealtimes for accuracy and neatness. 9. Supervises the maintenance of health and sanitation conditions in the department. 10. Checks temperatures at every meal.” D. During an observation in the kitchen on 1/29/25 at 9:07 AM, this surveyor asked the Dietary Manager to demonstrate thermometer calibration. She was able to successfully calibrate the thermometer calibration on the third attempt. E. In an interview with the Dietary Manager and Production Supervisor at the time of the calibration, this surveyor asked how often the thermometers were calibrated. The Production Supervisor said, “about once a week”. She stated they do not log the thermometer calibrations. F. The Surveyor requested the manufacturer’s instructions for use and calibration of the thermometer. This documentation was not provided. G. The findings in A, B, C, D, and E were verified by the Dietary Manager at the time of the observation. Based on policy and procedure review, job description review, observation, and interview, the Food Production Supervisor failed to ensure juices that had been poured from a large container into smaller 4-ounce containers were dated in one of one refrigerator and failed to remove expired food items from shelves in the nourishment room. This failed practice did not ensure expired food items from the nourishment room were not served to patients and did not ensure food safety/sanitation to avoid sources and transmission of infection and had the likelihood of any patient that was served food from the nourishment room. Findings follow: A. Review of policy and procedure titled Dietary Services noted dated, showed, “L. Leftovers: All leftover cold food for storage in refrigerator is put in storage containers. These items are named, labeled and dated. All juices left over are poured into a container with lids labeled and dated. All leftover foods will be discarded after 72 hours.” B. Review of policy and procedure titled Storage showed, “Policy: correct storage procedures will be followed by all dietary personnel.” “Procedure: 6. All foods stored in the refrigerator will be tightly covered. Leftovers will be covered, labeled, and dated. Leftovers will be destroyed within 72 hours.” C. Review of job description titled Food Production Supervisor, showed, “A. Function-supervises and coordinates the activities of employees in the food production areas. Responsible for receiving and storing of all department supplies. B. Duties- 7. Processes orders and relays messages from nursing service and other areas. 9. Supervises the maintenance of health and sanitation conditions in the department.” “Responsibilities: Under general supervision, the person must supervise and coordinate the activities of the employees of the production area of the kitchen, both a.m. & p.m. shift as needed. Do daily inspection of overall department. Maintain cleanliness and safety standards according to policy of department and facility, QA (Quality Assurance) monitoring recorded as needed. Receive, stock and rotate food items when delivered. Ensure all items are properly labeled & dated in storeroom, cooler/freezer. Leftovers utilized or discarded.” D. During a tour of the nourishment room on 01/27/25 from 2:37 PM to 3:15 PM, the following items were in the refrigerator and on the shelves: 1) Six-4-ounce containers of orange juice with no date 2) Five-4-ounce containers of grape juice with no date 3) Six-4-ounce containers of apple juice with no date 4) One-4-ounce container of orange juice was dated 1/13/25 5) Six fig bars with no expiration date 6) Approximately fifty packages of saltine crackers with no expiration date 7) Approximately seventy-five packages of graham crackers with no expiration date 8) One-42-ounce container of Oats expired 5/23/24 9) Two-unopened large aluminum foil type pouches of coffee packets with no expiration date 10) One-opened large aluminum foil type pouch of coffee packets with no expiration date 11) One-8-ounce yellow mustard expired 2/23/24 12) One-3-ounce steak seasoning expired 12/2/23 13) One-3-ounce steak seasoning expired 2/1/24 14) One-3-ounce crushed red pepper expired 1/14/22 15) One-3-ounce hamburger seasoning expired 11/14/23 16) One-5-ounce Himalayan pink salt expired 10/4/21 17) One-1-pound plastic container breakfast blend coffee-almost empty expired 9/15/24 E. During an interview with the Dietary Manager on 1/27/25 at 3:15 PM, she confirmed the findings in A-D and stated that juice items in the refrigerator were only “good” for three days from the date they were poured into the three-ounce containers from the larger containers and should be dated with the expiration date. Based on policy and procedure review, observation, and interview, the Dietary Manager failed to maintain food safety/sanitation for 3 of 3 bulk items (sugar, flour, and cornmeal) in one of one kitchen in that the bulk items were in plastic containers with lids that were loose fitting and not secured. The bins each had a label applied to them that 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 who was served meals that had been prepared with sugar, flour, or cornmeal. Findings follow: A. Review of policy and procedure titled, “Storage” last updated11/12/19 showed, “Policy: Correct storage procedures will be followed by all dietary personnel. 4. Bulk material such as sugar, flour, meal, beans, and rice will be stored in seamless metal or plastic containers with lids.” B. During a tour of the kitchen on 1/28/25 from 8:05 AM to 8:40 PM, there were three large plastic bins on wheels. 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. The clear plastic lids on the bins easily moved when touched and were not secured. Each bin had a label applied on the outside with a date written on the label. The label did not indicate whether it was the date the items were poured into the bins or the expiration date. C. In an interview with the Dietary Manager 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 could not state the loose lids would prevent potential staff, insect or vermin contamination. She confirmed the findings in A, B, and C at the time the observation and interview occurred. Based on policy and procedure review, review of Arkansas State Board of Health Rules for Hospitals and Related Institutions, observation, and interview, the Dietary Manager failed to maintain a sanitary environment in that the restroom in the kitchen area was being used as a storage area for clean supplies, staff uniform jackets/chef’s coat, and cleaning products. This failed practice did not ensure that clean supplies/clothing would not be contaminated by splashes from the toilet, sink or cleaning supplies and patients and/or staff would not be exposed to infectious pathogens or toxic chemicals. This failed practice had the likelihood of affecting any employee who used that restroom and any patient that had food prepared/served by employees who used that restroom. Findings follow: A. Review of policy and procedure titled “Storage” showed, “Cleaning materials will not be stored areas with food. They will be stored in a cabinet used for this purpose only.” B. Review of policy and procedure titled “Dietary Services” showed, “Purpose: To prevent contamination of food products and therefore prevent foodborne illness. 1. Director of Food Services (Dietary Manager) Responsibilities-A. Provide safe food services for patients and employees. 5. Food Storage D. Toxic cleaning materials must be identified, stored, and used in such a manner as not to contaminate food. They are stored in a separate room.” C. Review of Arkansas State Board of Health Rules for Hospitals and Related Institutions Section 18 A. General-5. There shall be policies and procedures establishing and defining the Infection Prevention and Control Program to include: f. A plan for monitoring and evaluating at least the following areas or departments to ensure policies and procedures are followed: 7) Food and nutrition; l. 5) Sanitary food preparation;” D. During a tour of the kitchen on 1/28/25 at 8:45 AM, there was a door that opened into a restroom. There was a wire 4-shelf storage unit less than three feet from the toilet. Shelf #2 contained multiple different types of cleaning supplies. Shelf #3 contained three opened rolls of paper towels and four opened rolls of toilet paper. The shelf also contained eight boxes of XL disposable gloves, six boxes of large disposable gloves, and four boxes of medium disposable gloves. In the same bathroom within three feet of the toilet and sink a wire rack for hanging clothes with a wire shelf on the top. The hanging rack contained three uniform (scrub) jackets and one chef’s coat. The wire shelf on top of the wire hanging rack contained two boxes of KN95 masks, one box of adhesive bandage strips and one pair of soiled cloth gloves. E. In an interview with the Dietary Manager at the time of the tour, the findings in A-D were confirmed. 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, and the Observation Unit, and all rooms in the hospital that had curtains. 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. Review of “Expired Dates of Supplies and Drugs and Cleaning Schedule Policy and Procedure”on 01/28/2025 at 2:30 PM, showed “In order to maintain all supplies and floor medications are within the acceptable date range and all areas are clean a systematic schedule has been set. Each shift will be accountable for a portion of the checks and should perform them as directed. The log will be kept at the nurse’s desk and should be signed and dated when completed. All staff is accountable to keep areas clean and supplies within date within the assigned time frame and should take advantage of slow days to accomplish the monthly checks.” B. Observation of the Emergency Department showed the following expired supplies: 1) Quantity #2: 18 French 5 cc foley catheters, expired 10/25/2024 2) Quantity #2: 18 French 30 cc Foley catheter, expired 10/31/2024 3) Quantity #4: BD vacutainer lab collection tubes, expired 12/31/2024 4) Box of Ethicon 4.0 Silk, expired 11/20/2024 5) Quantity #4: Pediatric Foam Electrocardiogram electrodes, expired 08/23/2024 6) Quantity #5: Curad Petroleum dressings, expired 09/30/2024 7) Quantity #2: Betadine Iodine Swab sticks, expired on 10/2024 8) Quantity #4: Hibiclens bottles, expired 12/2024 C. Observed of the Emergency Department showed the following clean supplies were stored in the Janitor’s Closet: 1) Quantity #3: Suction tubing 2) Quantity #7: Opened pullup diapers 3) Quantity #1 box: Patient bags 4) Quantity #1 box: Cleansing wipes 5) Basket of dirty linens 6) Biohazard waste container D. Observation of the Emergency Department showed the following clean supplies were stroed in the bathroom: 1) Quantity #18: Clean urine specimen cups 2) Quantity #6: Male urinals 3) Quantity#26: Lab specimen bags E. Observation of the Observation Unit showed the following expired supplies: 1) Quantity #34: Soft touch adult nasal oxygen canula 7 inches 2) Quantity #15: Patient bags 3) Quantity #35: Adult aerosol mask 4) Quantity #29: Airlife small volume nebulizer 5) Quantity #19: Washable cloth chucks 6) Quantity #4: Soft touch adult nasal canula 25 feet 7) Quantity #5: Vyare extension tubing, expired 03/09/2024 8) Quantity #2: Adult nasal canula high flow 2.5 feet 9) Quantity #8: Adult non-rebreathing mask with safety vent 2.1-star lumen tubing 10) Quantity #10: Suction Canister holders 1000 milliliters 11) Quantity #5: Suction Canister holders 3000 milliliters 12) Quantity #12: Airlife Misty Max 10 nebulizer 7 inches 13) Quantity #16: 6 inches x 6 inches pillows 14) Quantity #1: Hand restraint 15) Quantity #3: Baby blankets 16) Quantity #24: Baby shirts 17) Quantity #8: Airlife updraft kit with face mask 18) Quantity #3: Simple 02 mask, 1 opened and sticky 19) Quantity #5: Humidifier Airlife Sterile H2O 500 milliliters 20) Quantity #2: Bubble Humidifier 21) Quantity #6 IS 4000 milliliters 22) Quantity #1: Vibrating PEP Therapy System, expired 08/23/2022 23) Quantity #2: Feeding bag flush pump, expiration 02/29/2024 24) Quantity #17: Ear Mates 25) Quantity #4: ABG kits 26) Quantity #1: Pulse oximeter adhesive 27) Quantity #2: Hudson RCI Pressure Line Adapter 28) Quantity #1: Aero Chamber-Z Stat-Anti-static Valved Holding 29) Quantity #1: Aero Chamber-Z Stat-Anti-static Valved Holding with comfort seal mask F. Observation of the Medical/Surgical Unit showed mice feces in the kitchenette. G.Observation of the Medical/Surgical Unit showed the following clean supplies were stored with dirty supplies in the storage room: 1) Dirty blanket in the tub 2) Dirty floors 3) Medical equipment not delineated as clean F. Observation of the Janitors office on the medical surgical floor showed the following: 1) Quantity #2: Dirty mops 2) Quantity #2: Dirty brooms 3) Quantity #10: Cardboard boxes 4) Quantity #6: Cleaning supplies in cardboard boxes G. In an interview with the Chief Nursing Officer on 01/28/2025 at 2:15 PM, she stated that “I have never seen the policy for expired dates of supplies and drugs and cleaning schedule.” H. In an interview with the Environmental Services Manager on 01/28/2025 at 8:45 AM, when asked how she cleans the curtains throughout the hospital, she stated that “We spray the curtains after every patient leaves. We use an ultraviolet light to see the dirty spots we missed. We spray the curtains until the dirty spots are gone. We do not have a policy for laundering the curtains.” I. The Chief Nursing Officer verified the findings in A-F at the time of the observation.”

“Nursing leadership. CFR(s): (b)The director of the nursing service must be a licensed registered nurse. The individual is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the REH. This Standard is not met as evidenced by: 50014 Based on policy and procedures review, observation, and interview, it was determined that the facility failed to ensure a Registered Nurse was staffed on all units at all times. By not ensuring that a registered nurse was present, the facility failed to provide recognized standards of practice for the patient in the event of an emergency. The failed practice had the likelihood to affect all patients on the Observation Unit. Findings follow: A. Review of Registered Nurse (RN) Staffing Policy and Procedure dated 08/24/2001, showed, “At all times, there will be two RNs scheduled and on site at DeWitt City Hospital. One RN for each department, floor and Emergency Room. During times of low census - six patients or less - one RN will be designated to be on call for the Emergency Room. The on-call RN will not be assigned patients on the floor. Call will consist of the designated RN being on site at all times during the scheduled shift ...” B. Review of the Rules for Hospitals and Related Institutions in Arkansas, Section 11: Patient Care Services section 11:C Staffing showed “There shall be an adequate number of RNs on duty at all times and available for bedside care of any patient when needed on a 24-hour basis. In addition, there shall be sufficient RNs to staff all patient care units. A RN shall assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the preparation and competence of the nursing staff. There shall be written criteria to substantiate the assignments.” C. On 01/27/2025, the surveyor observed the licensed practical nurse (LPN) on the floor without a RN to assist her. D. In interviews on 01/27/2025 at 1:00 PM, at 2:00 PM and at 3:30 PM, LPN #4 was asked where RN #1 was during their shift. Three different times, she replied, “RN #1 is assisting in the Emergency Room.” E. In an interview with the Chief Nursing Officer (CNO) on 01/28/2025 at 3:45 PM, the CNO provided a policy regarding staffing on the observation floor and the emergency department. The surveyor asked “Is it ok for the RN to leave the LPN alone with a patient load?” She replied, “Yes it is!” The surveyor shared the Rules for Hospitals and Related Institutions in Arkansas, Section 11: Patient Care Services section 11:C Staffing. The CNO stated, “I did not know that rule.” F. The CNO verified the findings of A-D at the time of the interview.”

“Notice of rights. CFR(s): (a)(2) The REH must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. The REH’s governing body or responsible individual must approve and be responsible for the effective operation of the grievance process and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. The grievance process must include a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate Utilization and Quality Control Quality Improvement Organization. At a minimum: (i) The REH must establish a clearly explained procedure for the submission of a patient’s written or verbal grievance to the REH. (ii) The grievance process must specify time frames for review of the grievance and the provision of a response. (iii) In its resolution of the grievance, the REH must provide the patient with written notice of its decision that contains the name of the REH contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 46733 Based on review of Patient Rights form, policy and procedure review, and interview the governing body failed to establish a process for the prompt resolution of grievances and failed to establish a process to inform patients whom to contact to file a grievance, failed to maintain and be responsible for an effective grievance process to review and resolve grievances. This failed practice did not ensure a clearly explained procedure for the submission of a grievance, the time frames for the review of a grievance and provision of a response, written notice of steps taken to investigate the grievance, the results of the grievance process and the date the process was completed. Findings follow: A. Reviews of documentation provided by the facility showed the facility did not have a Grievance Log. This documentation was requested, and the facility could not provide. B. Review of Patient Rights form signed by and given to patients on admission to the facility did not describe a grievance process. C. Review of facility policy and procedure manuals showed no policy and procedure for the Grievance Process. The facility could not provide a policy or procedure for the Grievance Process. D. In an interview with the Chief Nursing Officer (CNO) on 1/28/25 at 2:55 PM, she stated the facility did not have a Grievance Process/Log, she stated that the current process was patient, visitor, family member concerns/issues were reported to the Chief Executive Officer (CEO) or her and they attempted to resolve the issue/s at the time they were reported. She stated there was no written documentation for this process. E. The CNO confirmed the above findings in A, B, and C at the time of the interview”

“Privacy and safety. CFR(s): (c)(2) Receive care in a safe setting. This Standard is not met as evidenced by: 50014 Based on policy and procedure review, observation and interview, it was determined that the facility failed to provide a safe environment in the Emergency Department trauma room by having an enzymatic solution in a glass jar with a dispensing lid by the sink. By not storing the enzymatic solution properly placed the patients at risk of ingestion or topical exposure of the solution and had the likelihood to affect all patients being treated in the Emergency Department trauma room. Findings follow: A. Review of DeWitt Hospital Policy and Procedures on 01/28/2025 at 1:45 PM, showed “All instruments will be prewashed with Alconox cleaning solution according to manufacturing instructions and taken to our central supply area.” B. Review of Safety Data Sheet for Alconox dated 12/31/2013, identified Alconox as a hazard. It was listed as a corrosive that can cause eye damage and a skin irritant. C. Observation on 01/27/2025 at 1:15 PM, showed a glass jar with a dispensing lid sitting in a rusted metal basket on the sink in Trauma Room #1 D. In an interview with the Chief Nursing Officer on 01/28/2025 at 3:00 PM, she stated that “I am not sure why that was in the Trauma Room #1. We do not use that and have not in a long time.” The Chief Nursing Officer verified A-C at the time of the interview.”

“Building safety. CFR(s): (d)Except as otherwise provided in this section, the REH must meet the applicable provisions and must proceed in accordance with the 2012 edition of the Health Care Facilities Code (NFPA 99, and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5 and TIA 12-6). (1) Chapters 7, 8, 12, and 13 of the adopted Health Care Facilities Code do not apply to an REH. (2) If application of the Health Care Facilities Code required under paragraph (d) of this section would result in unreasonable hardship for the REH, CMS may waive specific provisions of the Health Care Facilities Code, but only if the waiver does not adversely affect the health and safety of patients. This Standard is not met as evidenced by: 47688 Based on observation of the Emergency Department, Patient Hall, Medical Records, Medicine Room, Respiratory Therapy Department, Laundry Department, Computerized Tomography (CT) room, Ultrasound room, Laboratory, Ambulance entrance, Exam rooms, Clean Work Room, Mechanical Room 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 Exams rooms on 01/27/25 at 12:18 PM showed the following: 1) Wall damaged and peeling in Exam Room 2 2) Damaged counters in Exam Room 2 3) Floor Damage in Exam Room 3 4) All the doors in the exam room area are damaged and not sealed B. The findings in A were verified by the Director of Maintenance on 01/27/2025 at the time of observation. C. Observation of the Medical Records Department on 01/27/2025 at 1:31 PM showed ceiling tiles that were damaged. D. The findings in C were verified by the Director of Maintenance on 01/27/2025 at the time of observation. E. Observation of CT Room on 01/27/2025 at 1:28 PM showed the following: 1) Items were stored under the sinks 2) The sink needed to be cleaned and cleared of rust and calcium build up F. The findings of E were verified with the Director of Maintenance on 01/27/2025 at the time of observation. G. Observation of the Clean work room on 01/27/2025 at 1:40 PM showed: 1) There was exposed and damaged wood under the sink 2) Damaged wall paint H. The findings of G were verified with the Director of Maintenance on 01/27/2025 at the time of observation. I. Observation of the Laboratory on 01/27/2025 at 1:43 PM showed the following: 1) Wall penetrations throughout the lab 2) Moisture damaged to the walls under the air unit 3) Door closer damaged on door leaving the lab in cooler/fridge area J. The findings of I were verified with the Director of Maintenance on 01/27/25 at the time of observation. K. Observation of the Mechanical room on 01/27/2025 at 1:48 PM showed the following: 1) Door damage to the door leading onto the roof 2) A section of the wall missing under the stairs leading into the mechanical room L. The findings of K were verified with the Director of maintenance on 01/27/2025 at the time of observation. M. Observation of the Ambulance Entrance on 01/27/2025 at 1:58 PM showed the following: 1) Small wall penetration on the right-hand side of the automatic door 2) Damaged to the trauma room door N. The findings of M were verified with the Director of Maintenance on 01/27/2025 at the time of observation. O. Observation of the Emergency Department waiting room on 01/27/2025 at 2:10 PM showed the following: 1) The sprinkler head in the men’s restroom was too low 2) The pull cords in the men’s and women’s restrooms were more than 6 inches from the floor P. The findings of O were verified with the Director of Maintenance on 01/27/2025 at the time of observation. Q. Observation of the Ultrasound room on 01/27/2025 at 2:01 PM showed the following: 1) There was a damaged ceiling tile hanging from the ceiling 2) There was moisture damage on ceiling tiles R. The findings of Q were verified with the Director of Maintenance on 01/27/2025 at the time of observation S. Observation of the Respiratory Therapy department on 01/27/2025 showed the following: 1) Ceiling tiles were damaged 2) Moisture damage and a black substance was on the inside of the storage closet 3) Rust on the door frame of the storage closet T. The findings of S were verified with the Director of Maintenance on 01/27/25 at the time of observation. U. Observation of the Receiving room in the Laundry Department on 01/27/2025 at 2:16 PM showed the shelving on the receiving room was damaged and had exposed wood and not sealed. V. The finding of U was verified with the Director of Maintenance on 01/27/2025 at the time of observation W. Observation of the Patient Hall on 01/27/2025 at 2:30 PM showed the following: 1) Sleep room 100 had damaged furniture with exposed wood that was not sealed 2) Sleep room 102 had damaged furniture with exposed wood that was not sealed 3) Sleep room 102 had an electrical socket that was damaged. 4) Sleep room 102 had a light fixture that had bugs inside of it that needed to be cleaned 5) Room 108 had leaking and moisture damage under the window 6) Room 100 had paint that was lifting and damaged on the wall at the entrance of the room 7) Room 113 had a damaged handrail in the bathroom 8) Environmental Services closet had a sprinkler head that was too low 9) The clean room had damaged and peeling Formica 10) The Medicine room had dirty or a black substance on the vents that need to be cleaned 11) The medicine room had items being stored under the sink 12) The Nourishment room had cabinets that were damaged and exposed wood that was not sealed 13) The Nourishment room had damaged and peeling Formica X. The findings of W were verified with the Director of Maintenance on 01/27/2025 at the time of observation. Y. Observation of the Fire walls in the Main Hallway leading into the Patient Hall on 01/27/2025 at 3:09 showed the following: 1) Multiple firewall penetrations 2) The wrong type of fire caulk or foam being used to seal penetrations on the firewall Z. The findings of Y were verified with the Director of Maintenance on 01/27/2025 at the time of observation.”