College Medical Center Phoenix

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 49638 Based on Hospital policy and procedure, Hospital documents, medical record review, video footage review, and employee interview, it was determined the Hospital failed to ensure implementation of restraint technique occurred pursuant to Hospital policy and training. This deficient practice poses a potential risk to patient health and safety when restraint is not implemented according to policy and training. Findings include: Hospital policy titled “Restraint and Seclusion,” Policy #PC-001, Revision Date: 1/2026, revealed “ ...Procedures ...2. Patient safety, design, and the least-restrictive approach must guide all decisions; clinical benefit and legal requirements must be balanced with recovery-oriented care ....” Hospital training document titled “Advanced Physical Skills ...Emergency Floor Holding: Supine (Supporting Legs)” revealed “ ...In this position, you may need to restrict the movement of the person’s legs ...First staff member supporting legs ...Begin with the Supportive Stance, approaching from the side, facing the person with your back towards their feet ...Step close with your foot, nearest the person, and kneel. Please your knee close, making contact with the person’s knees with your hands ...Maintain contact with the person’s knees, lowering your body over their thighs ...Place your arm, nearest to the person, beneath their thighs, reaching back towards yourself, keeping their legs close together ...Place your arm, furthest from the person, over their thighs, lowering your upper over the legs as much as you can ...Adjust your Supportive Stance so your thigh, nearest the person, is close to theirs ...Adjust the position of your leg, furthest from the person, so you remain balanced and stable ...Remain close in the Supportive Stance and apply the Outside principle to help maintain an Emergency Floor Hold ....” The medical record for Patient #8 revealed the following: Document titled “Seclusion/Restraint Packet,” dated 1/15/2026, revealed “ ...Type ...Personal/Physical Restraint (box checked) ...Start: 0330 ...Stop: 0337 ....” Video footage review of Patient #8 titled “AP1 Pack Common 1 (1),” dated 1/15/2025, revealed the following: 0:07:43 of the video timer: Patient #8 is observed in a supine position on the floor, in his/her bedroom doorway, during staff application of restraint. 0:07:45 of the video timer: An unidentified staff approaches Patient #8’s legs from a standing position and, with his/her left foot, moves Patient #8’s left leg together with his/her right leg, holding his/her foot in this position until 0:07:57 of the video timer. Employee #7 confirmed, during interviews conducted from January 16, 2026 to January 20, 2026, that the physical intervention utilized with Patient #8, as noted from the “AP1 Pack Common 1 (1)” video footage review, was not a trained intervention.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 50979 Based on hospital policies and procedures, hospital documentation, medical record review, and employee interview, the Department determined the Hospital failed to implement their quality management program by ensuring that the hospital followed their policies and procedures related to investigating Patient Safety events. This deficient practice resulted in inaccurate documentation and poses a potential risk to the health and safety of patients when potential system or individual performance problems may not be addressed. Findings include: Hospital policy #QM-004, titled “Management and Internal Reporting of Serious Safety Events,” last revised 10/2025, revealed: “...The Quality Director will complete an incident review and assign final categorization of type, injury and severity ...Ensuring the investigation, debriefings, interview and corrective actions are completed including process of root cause analysis is the responsibility of the Quality Department ....” Hospital document titled “Behavior Event,” dated 10/13/2025, referenced Patient #4 and revealed “ ...Date of Event ...10/12/2025 ...Event Time ...21:00 ...Patient Behavior Event Type ...Physical Assault ....” Hospital document dated 11/04/2025, summarized that Patient #4 sustained a “ ...minor injury ...” from the event dated and timed 10/12/2025 at 21:00, and was “ ...sent for medical clearance and returned ....” Medical record review for Patient #4 revealed no documentation of a send-out of Patient #4 for medical clearance. Employee #3 confirmed, during an interview conducted on November 20, 2025 and following review of the Hospital document dated 11/04/2025, that Patient #4 was not sent out for medical clearance, as summarized in the document.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 45202 Based on review of hospital records and staff interviews, it was determined that the hospital failed to comply with protecting and promoting patient’s rights as evidenced by: Cross reference A-0123: The hospital failed to complaint response policy was followed. Cross reference A-0144: The hospital failed to ensure care was provided in a safe setting resulting in an Immediate Jeopardy. Cross reference A-0168: The hospital failed to ensure the use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. Cross reference A-0175: The hospital failed to ensure policy and procedures are established, documented, and implemented in relation to non-licensed employee supervision. Cross reference A0178: The facility failed to ensure staff followed assessment processes when patients are placed in seclusion and/or restraint. These systemic deficient practices and egregious nature of these deficient practices resulted in the facility’s failure to meet the requirement for the Condition of Participation for Patient Rights and provide a safe environment for patients to protect them from harm.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 45202 Based on hospital policy and procedure review, hospital documentation review, employee file review, and employee interview, it was determined that the hospital failed to meet the requirement of the Conditions of Participation for Nursing Services as evidenced by the following reference to standard-level deficiency: Cross reference A-0392: The Nurse Executive failed to ensure staff are knowledgeable about the hospital’s acuity plan, and how to implement it. Cross reference A-0395: The Nurse Executive failed to ensure proper oversight of unlicensed staff. The egregious nature of this deficient practice resulted in the facility’s continued failure to correct this deficient practice and meet the requirement for the Condition of Participation for Nursing Services and failure to provide appropriate oversight of nursing services at the Hospital.”

“COMPLIANCE WITH LAWS CFR(s): 482.11(a) The hospital must be in compliance with applicable Federal laws related to the health and safety of patients. This Standard is not met as evidenced by: 45202 Based on hospital policy and procedure review, patient medical record review and request, and employee interview, the Department determined that the administrator failed to ensure that staff responded to patient allegations of sex trafficking, per hospital policy. This deficient practice poses a potential risk of patients not receiving appropriate support and resources in order to effectively address the physical and mental health issues associated with sex trafficking while receiving hospital services, which could increase the risk of harm or death to patients. Findings include: Review of hospital policy titled “Suspicion of Patient Abuse,” policy #1.14, reviewed 7/2025, revealed “ ...Suspected Sex Trafficking ...If the patient is in immediate danger contact the policy right away ...If it ’ s (sic) not immediate emergency contact ...APS via phone or through the online portal ...Contact the Arizona Human Trafficking Tip Line ...anonymously through the Arizona Counter Terrorism Information Center ...Notify the patient ’ s provider and clinical care team of the suspected trafficking ....” Review of hospital policy titled “Patient Rights and Responsibilities,” policy #RI 45, revised 03/2025, revealed “ ...Patient Rights ...Be free from any form of abuse ...and have access to protective and advocacy services ....” Review of patient #2 ’ s medical record revealed the following: A “Psych Nurse Admit Note,” dated July 16, 2025, revealed “ ...Patient report ...Mother using ...for sex trafficking ....” A “PHX Inpatient Psychosocial Assemt (sic),” dated July 17, 2025, revealed “ ...patient believes ...being sex trafficked ....” A request was made for documentation verifying that Adult Protective Services (APS), Arizona Human Trafficking Tip Line, and/or Arizona Counter Terrorism Information Center was contacted. None was provided during the time of survey. An interview with employee #9, completed on September 4, 2025, confirmed that patient #2 ’ s documentation for contacting APS, Arizona Human Trafficking Tip Line, and/or Arizona Counter Terrorism Information Center, could not be provided.”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital 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: 52829 Based on hospital policy and procedure review, hospital documentation review, and employee interview, the Department determined that the administrator failed to ensure that policy was followed by staff regarding patient complaints. This deficient practice poses a potential risk of staff not addressing patient needs, which poses a risk to the health and safety of patients. Findings include: A review of hospital policy titled “Patient Complaints and Grievances,” policy #RI 58, reviewed 7/2025, revealed “ ...When possible, grievance investigations will be completed, within 10 days of receipt ...If the grievance is not resolved, or if the investigation is not completed, within 10 days of the grievance receipt, the Patient Advocate will send an acknowledgment letter to inform the grievant that the hospital is still working to resolve the matter ....” A review of hospital policy titled “Patient Rights and Responsibilities,” policy #RI 45, revised 03/2025, revealed “ ...Patient Rights ...Be advised of the hospital ’ s grievance process ...regarding quality of care ...Notification of the process includes whom to contact to file a grievance, and ...will be provided a written notice of the grievance determination ....” A review of patient #6 ’ s hospital documentation revealed that a claim was made on 07/28/2025 that patient #6 was missing personal belongings and valuables. An acknowledgement letter confirming the search for patient #6 ’ s personal belongings and valuables was still in process, was not sent to patient #6 until August 8, 2025, 11 days after the claim was received. In an interview conducted on September 5, 2025, employee #2 confirmed that policy regarding the patient complaint process was not followed by staff.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 45202 Based on hospital policy and procedure review, patient medical record review, hospital documentation review, and employee interview, the Department determined that the administrator failed to ensure policies and procedures are implemented to ensure care was received in a safe setting. This deficient practice poses a risk of incident concerns related to patient care not being addressed in order to improve patient outcomes, which poses a threat to the health and safety of patients and resulted in an Immediate Jeopardy situtation as a result of patient injuries sustained. Findings include: Review of hospital policy titled “Suspicion of Patient Abuse,” policy #1.14, reviewed 7/2025, revealed “ ...Investigation Process ...Risk Management will ensure that an administrative investigation is completed ...investigative process will include ...interviews ...written statements by the individual reporting the allegation and all patients and staff involved ...Results of the ...investigation will be reviewed by the director of quality, nursing manager and chief nursing officer ....” Review of hospital policy titled “Reporting Serious Incidents and Accidents to State Department of Health (DPH/DOH), Department of Mental Health (DMH) and Centers of Medicare and Medicaid Services (CMS),” policy #R12, revised 03/2025, revealed “ ...Any employee who believes that an SRE (sic) has occurred shall report the event immediately to ...Supervisor ...immediate supervisor will ...communicate with ...Risk Manager ...to begin investigation ....” Review of hospital policy titled “Medical Staff Bylaws March 2025,” revealed “ ...Medical peer review committee ...responsible for ...the determination of whether health care services were performed in compliance with the applicable standards of care ...on ...incident ...specific ...basis ....” Review of patient #1 ’ s “Progress Note Non-Physician,” dated August 26, 2025, revealed “ ...Pt was placed on a physical hold ...While on hold, Pt hit ...forehead and ...reported a headache ...Patient noted to have an abrasion and swilling to R upper eye, abrasion and redness to L upper arm, scratches and bruise to L jaw, and abrasions and redness to bilateral knees ....” Review of medical records from receiving emergency facility confirms that Patient #1 suffered a concussion and bruised ribs. Review of patient #1 ’ s hospital documentation, dated 8/26/25, revealed sections including staff statements, patient interviews, documents included, corrective actions, signatures, regulatory agency reporting, and review medical provider action, including date and medical provider signature, were incomplete. It further revealed that the Employee involved in the incident was places on leave pending investigation as a result of the incident. Employee #9 confirmed in an interview, conducted on September 5, 2025, that hospital documentation was incomplete for patient #1 and that injuries were sustained during the course of the staff intervention.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 52829 Based on hospital policy and procedure review, medical record review and request, and employee interview, the Department determined that the hospital administrator failed to ensure that processes related to obtaining provider orders for physical and chemical restraints were implemented. This deficient practice poses a potential risk of patients (pt(s)) not receiving care as ordered by a provider, which poses a potential risk of harm to the health and safety of patients. Findings include: A review of hospital policy titled “RULES AND REGULATIONS OF THE MEDICAL STAFF 03/2025,” revealed “ ...ORDERS ...General Procedures ...All orders for treatment shall be in writing, be legible, and be signed by the ordering practitioner ....” A review of hospital policy titled “Seclusion and Restraint,” policy #BHU-00-164, revised 07/2025, revealed “ ...All orders for restraints shall be dated and timed and shall include ...Type of restraint ...The behavior necessitating the use of restraints...Length of time the restraint may be utilized ...Alternative methods used to prevent the use of restraints ...Only a physician or Registered nurse may write a restraints order ...In clear case of emergency, the RN may authorize the use of restraints and obtain a telephone order form physician within one hour ...of application of restraints ...The physician must authenticate order within 24 hours of implementation ....” A review of patient #7 ’ s “Seclusion/Restraint Packet,” dated 8/25/25, revealed “ ...Personal/Physical Restraint ...Start: 2047 ...Stop: 2055 ...Mins: 8 ....” A request was made for patient #7 ’ s provider orders for the physical restraint on 8/25/25. None was provided during the time of survey. A review of patient #8 ’ s medical record revealed the following: A “Progress Note Non-Physician,” dated August 25, 2025, revealed “ ...pt was upset and hit one of the staff members ...pt was punching walls and tearing up the gym ...IM injections were ordered by provider ....” A “Seclusion/Restraint Packet,” dated 8/25/25, revealed “ ...Chemical Restraint ...Thorazine ...0910 ...100 mg ...once ...IM ...Benadryl ...0910 ...50 mg ...once ...IM ....” A request was made for patient #8 ’ s provider orders for the chemical restraint on 8/25/25. None was provided during the time of survey. An interview with employee #5 on September 5, 2025, confirmed that provider orders for patient #7 ’ s physical restraint on 8/25/25, and provider orders for patient #8 ’ s chemical restraint on 8/25/25, could not be provided.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 52829 Based on hospital policy and procedure review, hospital documentation review, employee file review, and employee interview, it was determined that the hospital failed to ensure Policy and procedures are established, documented, and implemented in relation to non-licensed employee supervision. These deficient practices pose risks of non-licensed employees providing services to patients that they have not been supervised by competent nursing staff to provide, which increases the risk of harm to the health and safety of patients. Hospital policy on clinical oversight was requested on survey conducted 9/2/2025 through 9/5/2025 and 9/8/2025, none was provided at time of survey Hospital document titled “Behavioral Health Technician (BHT) Clinical Site Record”, was produced by employee #6 who indicated this as the only documentation related to clinical oversight for BHT ‘s. A review of personnel records on 9/7/2025, identified employee #11, #13, #14, #15, #17, and #19 as Behavioral Health Technicians (BHTs.) Interview conducted 9/5/2025, employee #2, #5, #6, and #9 confirmed that policy on clinical oversight was not available for review. Employee #2, #5, #6 and #9 confirmed that no hospital policies addressed, delineate the services a behavioral health technician is allowed to provide at or for the health care institution, cover clinical oversight for a behavioral health technician, including documentation of clinical oversight, Establish the qualifications for a behavioral health professional providing clinical oversight to a behavioral health technician, delineate the methods used to provide clinical oversight, including when clinical oversight is provided on an individual basis or in a group setting, establish the process by which information pertaining to services provided by a behavioral health technician is provided to the behavioral health professional who is responsible for the clinical oversight of the behavioral health technician.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 52829 Based on hospital policy and procedure review, hospital documentation review, patient medical record review, and employee interview, the Department determined that the administrator failed to ensure staff followed assessment processes when patients are placed in seclusion and/or restraint. This deficient practice poses a risk that patient needs are not consistently assessed, and met while in seclusion and/or restraint, which poses a threat of harm or death to patients. Findings include: Review of hospital policy titled “Seclusion and Restraint,” policy #BHU-00-164, reviewed 07/2025, revealed “ ...Evaluations, Documentations and Monitoring ...A physician or other licensed independent practitioner must see (face to face) and evaluate the need for seclusion and restraints within 1 hour after the initiation of this intervention, the evaluation must be documented in the patient medical record ....” Review of hospital documentation titled “Seclusion/Restraint Packet- Monitoring Form,” revealed “ ...An RN (sic) must complete ...a Face to Face Assessment every HOUR (minimum) up until and including release ....” Review of patient #7 ’ s “Seclusion/Restraint Packet- Monitoring Form,” dated 8/25/25, revealed “ ...Time ...2047 ...Comments ...Restraint/seclusion initiated ....” Review of patient #7 ’ s “Seclusion/Restraint Packet- RN Hourly Face to Face Assessment,” dated 08/25/25, revealed “ ...Time ...of Assessment ...2150 ....” Review of patient #21 ’ s “Seclusion/Restraint Packet- Monitoring Form,” dated 9/01/25, revealed “ ...Time ...2211 ...Comments ...Restraint/seclusion initiated ....” Review of patient #21 ’ s “Seclusion/Restraint Packet- RN Hourly Face to Face Assessment,” dated 9/1/25, revealed “ ...Time ...of Assessment ...2320 ....” An interview with employee #9, conducted on September 4, 2025, confirmed that hospital policy and procedure related to assessment within one hour after initiation of seclusion/restraint, was not followed for patient #7, and #21.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 52829 Based on review of hospital policy and procedure, record reviews and staff interviews, the Department determined the nurse executive failed to ensure staff are knowledgeable about the hospital’s acuity plan, and how to implement it. This deficient practice poses a risk to the health and safety of patients when registered nurses do not know how to utilize, and implement the acuity plan for the determination of a patient’s acuity and safe patient assignments. Findings include: Policy titled, “Inpatient Staffing/ Acuity Plan and Patient Acuity Tool Guidelines “ POLICY # HR 15 Last Reviewed: 03/25, revealed: “ ...It is the policy of this hospital to ensure the appropriate number and skill mix of nursing personnel needed for each unit is determined after a registered nurse’s evaluation of the patients’ acuity level, unit activities, admissions and discharges... PROCEDURE: Patient Assignments ... The RN will review the current census at 0800 and 1700 hours daily ... The acuity rating for each unit will be submitted to the house supervisor by 0400 and 1600 hours daily ... An acuity rating for each patient is performed each shift at the designated time to project and facilitate the care needs and care requirements ... The RN will make staffing assignments as appropriate to patient needs and taking into consideration the specialized qualifications and competency of the nursing staff ... An RN will make BHT assignments based on individual patient care needs. BHTs are added to the staffing matrix based on patient care needs ... Acuity Tool The RN will date and sign the assignment sheet which includes acuity levels The RN will record the unit and the total acuity points for the respective unit ... indicators used to monitor staffing effectiveness/appropriateness of care include the ongoing monitoring of medication errors, patient falls, patient satisfaction and length of stay ... units may identify specific patient outcomes related to high risk/high volume patients ... Assess staffing needs once per shift for the upcoming shift ... The hospital shall take all reasonable steps to assure that there are sufficient numbers of qualified nursing staff members available at all times to meet the nursing care needs of patients in all applicable units and areas ....” Acuity tool for AP-1, AP-2, AP-3, and AP5 for the month of August was reviewed with the following missing AM acuity tools: AP-1 missing AM acuity tool for 8/2,6,8,9,10,15,20,24 AP-2 missing AM acuity tool for 8/2,3,4,5,10,11,12,13,17,18,19,24,25,26,27 AP-3 missing AM acuity tool for 8/3,6,8,9,10,11,13,15,16,18,20,27,28,29,30 AP-5 missing AM acuity tool for 8/3,5,17,18,19,24,25,26,30 Request made 9/5/2025 for the missing AM acuity tool for AP-1, AP-2, AP-3, and AP5, staff were unable to provide them for review during the survey. Interview conducted 9/5/2025, employee #2, #5, #6, and #9 confirmed that the AM acuity sheets for AP-1, AP-2, AP-3, and AP-5 were not available for review. Interview conducted 9/5/2025, employee #2, #5, #6, and #9 were asked how acuity for the days missing the acuity tool was determined to ensure sufficient number of qualified nursing staff were available to meet the needs of patients in all applicable units and areas, they were unable to provide how acuity was determined for the days missing AM acuity tools”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 52829 Based on hospital policy and procedure review, hospital documentation review, employee file review, and employee interview, it was determined that the Nurse Executive failed to ensure Policy and procedures are established, documented, and implemented in relation to non-licensed employee supervision. These deficient practices pose risks of non-licensed employees providing services to patients that they have not been supervised by competent nursing staff to provide, which increases the risk of harm to the health and safety of patients. Hospital policy on clinical oversight was requested on survey conducted 9/2/2025 through 9/5/2025 and 9/8/2025, none was provided at time of survey Hospital document titled “Behavioral Health Technician (BHT) Clinical Site Record”, was produced by employee #6 who indicated this as the only documentation related to clinical oversight for BHT ’ s A review of personnel records on 9/7/2025, identified employee #11, #13, #14, #15, #17, and #19 as Behavioral Health Technicians (BHTs.) Interview conducted 9/5/2025, employee #2, #5, #6, and #9 confirmed that policy on clinical oversight was not available for review. Employee #2, #5, #6 and #9 confirmed that no hospital policies addressed, delineate the services a behavioral health technician is allowed to provide at or for the health care institution, cover clinical oversight for a behavioral health technician, including documentation of clinical oversight, Establish the qualifications for a behavioral health professional providing clinical oversight to a behavioral health technician, delineate the methods used to provide clinical oversight, including when clinical oversight is provided on an individual basis or in a group setting, establish the process by which information pertaining to services provided by a behavioral health technician is provided to the behavioral health professional who is responsible for the clinical oversight of the behavioral health technician.”

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 52829 Based on Hospital policy and procedure, medical record, document request and employee interview, it was determined the Hospital failed to ensure orders were documented in the medical record for a patient receiving One to One (1:1) observation. This deficient practice poses a potential risk of harm to patients who are not being monitored as necessary, resulting from the absence of orders in the patient medical record. Findings include: Hospital policy titled “Nursing Supervision,” Policy #BH 02, Last Revised 3/2025, revealed “ ...Definitions ...One to one (1:1) Observation: Assignment of a qualified staff member to remain with the patient and maintain an unobstructed view of the patient at all times to prevent harm to the patient or others. The ordering licensed independent practitioner (LIP) may indicate the proximity to the patient at which the one to one (1:1) observation is conducted, if necessary ...Licensed Independent Practitioner (LIP): An individual permitted by law and by the organization to provide care, treatment, and services without direct supervision. A licensed practitioner operates within the scope of his or her license, consistent with individually granted clinical privileges. (This includes physicians and mid-level practitioners among others) ...B. Frequent Observation (Safety Checks) ...f. The RN may increase a patient’s level of observation, provided it is reasonably necessary, and an LIP order is obtained within an hour after increasing the level of observation ....” Hospital policy titled “RULES AND REGULATIONS OF THE MEDICAL STAFF 03/2025,” Adopted 03/20/2025, revealed “ ...ORDERS ...1. General Procedures: ...a. All orders for treatment shall be in writing, be legible, and be signed by the ordering practitioner ....” Medical record for Patient #21 revealed two (2) documents titled “1:1 Psychiatric High Risk,” one (1) dated 9/1/2025 and one (1) 9/2/2025. The start time on the document dated 9/1/2025 was 2222 and the end time on the document dated 9/2/2025 was 0315. Request was made for a corresponding One to One (1:1) order. None was provided. Employee #5 confirmed, during an interview conducted on September 4, 2025, that no order for One to One (1:1) observation was available for review at the time of the survey.”

“Treatment Plan - Modalities CFR(s): [The written plan must include] The specific treatment modalities utilized; This Standard is not met as evidenced by: 52829 Based on Hospital policy and procedure, medical records and employee interview, it was determined the Hospital failed to ensure provision of services to patients documented within patient care/treatment plans. This deficient practice poses a potential risk of harm to patients if care, based upon assessment of needs, is not provided. Findings include: Hospital policy titled “Care Planning,” Policy #POC 33, Last Revised 3/2025, revealed “ ...A. Content ...An individualized care plan will be developed and based upon the integration of interdisciplinary assessment findings, relevant past medical history and diagnostic studies, and will address the learning needs of the patient and/or family ...2. The plan of care is based on the goals time frames, settings, and services required ...3. Patients receive care and treatment based on an assessment of their needs, the severity of their disease, condition, impairment, or disability ....” Medical records revealed the following: Patient #5 Document titled “PHX Master Treatment Plan Text,” dated 04/04/2025, stated “ ...GH Evaluation Summary: To promote treatment compliance and reduce suicidal ideations patient will attend daily 30 to 60 minute recreational therapy groups to learn coping skills and distraction techniques ...” Recreation Therapy Group Notes for 4/12/25 and 4/13/25 were not available for review in Patient #5 ’ s medical record. Request for Recreation Therapy Group Notes for these dates was made. None were provided. Patient #10 Document titled “PHX Master Treatment Plan Text,” dated 08/11/2025, stated “ ...GH Evaluation Summary: To reduce agitation and promote treatment compliance, activity thearpy [sic] will teach (Patient #10) health mood regulation techniques and coping skills through daily 30-60 minute sessions ...” Recreation Therapy Group Notes for 8/23/25 and 8/24/25 were not available for review in Patient #10 ’ s medical record. Request for Recreation Therapy Group Notes for these dates was made. None were provided. Patient #12 Document titled “PHX Master Treatment Plan Text,” dated 07/04/2025, stated “ ...GH Evaluation Summary: To reduce delusions and auditory/visual hallucinations, activity therapy will teach (Patient #12) healhty [sic] reality orientation techniques and coping skills through daily 30-60 minute sessions ...” Recreation Therapy Group Notes for 7/5/25 and 7/6/25 were not available for review in Patient #12 ’ s medical record. Request for Recreation Therapy Group Notes for these dates was made. None were provided. Patient #13 Document titled “PHX Master Treatment Plan Text,” dated 06/23/2025, stated “ ...GH Evaluation Summary: To promote treatment compliance, a sober lifestyle, and reduce paranoid delusions patient will attend daily 30 to 60 minute recreation therapy groups ...” Recreation Therapy Group Notes for 7/28/25 and 7/29/25 were not available for review in Patient #13 ’ s medical record. Request for Recreation Therapy Group Notes for these dates was made. None were provided. Patient #14 Document titled “PHX Master Treatment Plan Text,” dated 07/21/2025, stated “ ...GH Evaluation Summary: To reduce hallucinations when unmedicated and promote treatment compliance and a lifestyle of sobriety, activity therapy willt each [sic] (Patient #14) sober coping and leisure alternatives through daily 30-60 minute sessions ...” Recreation Therapy Group Notes for 7/26/25 and 7/27/25 were not available for review in Patient #14 ’ s medical record. Request for Recreation Therapy Group Notes for these dates was made. None were provided. Patient #15 Document titled “PHX Master Treatment Plan Text,” dated 08/18/2025, stated “ ...GH Evaluation Summary: To reduce auditory and visual hallucinations and promote a sober lifestyle patient will attend daily 30 to 60 minute groups to learn distraction techniques and sober coping alternatives ...” Recreation Therapy Group Notes for 8/16/25 and 8/17/25 were not available for review in Patient #15 ’ s medical record. Request for Recreation Therapy Group Notes for these dates was made. None were provided. Patient #20 Document titled “PHX Master Treatment Plan Text,” dated 08/27/2025, stated “ ...GH Evaluation Summary: To reduce danger to self and others behaviors and hallucinations patient will attend daily 30 to 60 minute groups to learn distraction techniques and mood management techniques ...” Recreation Therapy Group Notes for 8/30/25 and 8/31/25 were not available for review in Patient #15 ’ s medical record. Request for Recreation Therapy Group Notes for these dates was made. None were provided. Employees #5 and #7 acknowledged, during interviews conducted on September 3, 2025 and September 4, 2025, that the Master Treatment Plans for Patients #5, #10, #12, #13, #14, #15, and #20 documented daily attendance in Recreation Therapy groups. Employees #5 and #7 reported no groups are held on weekend days, confirmed the dates the above-noted medical records did not contain Recreation Therapy Group Notes coincided with weekend days, and also confirmed no group notes were available for review, for these dates, at the time of the survey.”

“COMPLIANCE WITH LAWS CFR(s): 482.11 Compliance with Federal, State and Local Laws This Condition is not met as evidenced by: 43788 Based on review of documents, observations and interviews, it was determined the hospital failed to comply with state and local laws and regulations required for licensure. This deficient practice poses a risk to the health and safety of patients if hospitals are inappropriately providing services to patients which could lead to injury or death. Cross reference A0022, A0043, A0057, A0715 Findings include: A0022: The hospital: 1 . failed to ensure the hospital had obtained proper licensing for the kitchen used to prepare patient food. 2. failed to ensure the fire alarm system was inspected and maintained in accordance with the Phoenix Fire Code. 3. provided false and misleading information in the environment of care Immediate Jeopardy Corrective Action Plan by continuing to admit patients to the hospital’s intake area when the hospital was closed to patient admissions until Department approval. The cumulative effect of these systemic deficient practices resulted in the facility’s failure to meet the condition of Participation for Compliance with Laws requirements and provide a safe environment for patients to protect them from harm or death.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 43788 Based on the review of documents and staff interviews, it was determined that the Governing Body failed to ensure that the hospital operations, functions, and responsibilities are able to provide a safe and healthy environment for the patient population. These deficient practices pose a potential risk for patients of receiving inadequate care and treatment timely, which could lead to avoidable lengthy patient admissions, unwarranted development of disease complications, and probable poor patient prognosis. Findings include: A0020: The hospital failed to comply with state and local laws and regulations required for licensure. (Cross reference A0022, A0057) A0022: The hospital: 1 . failed to ensure the hospital had obtained proper licensing for the kitchen used to prepare patient food. 2. failed to ensure the fire alarm system was inspected and maintained in accordance with the Phoenix Fire Code. 3. provided false and misleading information in the environment of care Immediate Jeopardy Corrective Action Plan by continuing to admit patients to the hospital’s intake area when the hospital was closed to patient admissions until Department approval. (Cross reference A0020, A0057) A0057: The Chief Executive Officer (CEO) failed to manage the daily operation of the hospital. (Cross reference A0020, A0022, A0168, A0273, A0392, A0618, A0619, A0700, A0701, A0715, A0724, A0747, A0750) A0168: The hospital failed to ensure an order was made before restraint/seclusion was initiated. (Cross reference A0057) A0273: The hospital failed to ensure an incident report was completed for allegation of abuse for a patient (Patient #20). (Cross reference A0057) A0392: The hospital failed to ensure there were sufficient numbers of nursing staff to provide patient care according to hospital acuity plan. (Cross reference A0057) A0618: The hospital failed to provide organized dietary services to meet the nutritional needs of the patients in a sanitary and hygienic environment. (Cross reference A0057, A0619, A0700, A0747, A0750) A0619: The hospital failed to ensure: 1.kitchen staff wore hair nets; 2. the kitchen, kitchen carts, shelves, and equipment were cleaned, disinfected, and maintained; 3. refrigerator and freezer temperatures were monitored and interventions implemented for out of range readings;and 4. expired and outdated food products were discarded and not available for consumption; 5. food was stored appropriately in a clean and sanitary manner; and; 6. food temperatures were monitored and interventions implemented for out of range readings; (Cross reference A0057, A0618, A0700, A0747, A0750) A0700: The Hospital failed to maintain the physical environment of the hospital to protect the health and safety of patients. (Cross reference A0020, A0022, A0057, A0618, A0619, A0701, A0715, A0724, A0747, A0750) A0701: The Governing Body and the Hospital failed to ensure the facility was adequately maintained by: 1. failing to ensure kitchen equipment was maintained and operational. 2. failing to ensure HVAC System was maintained and operational. 3. failing to ensure fire alarms were maintained and operational. 4. failing to ensure elevators were maintained and operational. 5. failing to ensure plumbing leaks and drainage pipes were maintained and operational. (Cross reference A0020, A0022, A0057, A0618, A0619, A0700, A0715, A0724) A0715: The hospital failed to ensure fire alarms were maintained. (Cross reference A0020, A0022, A0057, A0700, A0701) A0724: The hospital failed to ensure the HVAC system was maintained in working order. (Cross reference A0020, A0022, A0057, A0700, A0701, A0715) A0747: The failed to meet the Conditions of Participation by failing to maintain and monitor the sanitary and hygienic environment of the kitchen. (Cross reference A0057, A0144, A0618, A0619, A0750) A0750: The hospital failed to ensure the kitchen area was maintained in a sanitary and hygienic manner. (Cross reference A0057, A0144, A0618, A0619, A0747) The cumulative effect of these systemic deficient practices resulted in the facility’s failure to meet the requirement for the Condition of Participation for Governing Body.”

“FOOD AND DIETETIC SERVICES CFR(s): 482.28 The hospital must have organized dietary services that are directed and staffed by adequate qualified personnel. However, a hospital that has a contract with an outside food management company may be found to meet this Condition of Participation if the company has a dietitian who serves the hospital on a full-time, part-time, or consultant basis, and if the company maintains at least the minimum standards specified in this section and provides for constant liaison with the hospital medical staff for recommendations on dietetic policies affecting patient treatment. This Condition is not met as evidenced by: 43788 Based on review of documents, observations and staff interviews, it was determined the hospital failed to provide organized dietary services to meet the nutritional needs of the patients in a sanitary and hygienic environment. This deficiency was identified in an Immediate Jeopardy. Cross reference A0043, A0057 A0619: The hospital failed to ensure: 1. kitchen staff wore hair nets; 2. the kitchen, kitchen carts, shelves, and equipment were cleaned, disinfected, and maintained; 3. refrigerator and freezer temperatures were monitored and interventions implemented for out of range readings;and 4. expired and outdated food products were discarded and not available for consumption; 5. food was stored appropriately in a clean and sanitary manner; and; 6. food temperatures were monitored and interventions implemented for out of range readings; An Immediate Jeopardy was identified as a result of the findings in A0619. The Hospital failed to be in compliance with the Conditions of Participation for Food and Dietetic Services. The cumulative effect of the facility’s systemic practices pose patient safety risks related to an increased risk of foodborne disease. Additionally, these deficient practices negatively impact the delivery of quality patient care if there is no oversight provided for the facility kitchen and dietary services overall functioning and performance.”

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 48110 Based on review of documents, observations, and interviews, it was determined that the Hospital failed to maintain the physical environment of the hospital to protect the health and safety of patients. Cross reference A0020, A0043, A0057, A0618, A0619, A0701, A0724, A0747, A0750) A0701: The Governing Body and the Hospital failed to ensure the facility was adequately maintained by: 1. failing to ensure kitchen equipment was maintained and operational. 2. failing to ensure HVAC System was maintained and operational. 3. failing to ensure fire alarms were maintained and operational. 4. failing to ensure elevators were maintained and operational. 5. failing to ensure plumbing leaks and drainage pipes were maintained and operational. A0715: The hospital failed to ensure the fire alarm system was inspected and maintained in accordance with the Phoenix Fire Code. A0724: The hospital failed to ensure the HVAC system was maintained in working order. The cumulative effect of the severity of this systematic deficient practice resulted in the facility’s failure to meet the requirement for the Condition of Participation for Physical Environment, which poses a potential risk to the health and safety of patients.”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 43788 Based on review of documents, observations, and interviews, it was determined that the Hospital failed to meet the requirement of the Condition of Participation for Infection Prevention and Control as evidenced by the following standard level deficiency that was identified in an Immediate Jeopardy. Cross reference A0043, A0057, A0144, A0618, A0619, A0700, A0701, A0750 Findings include: A0750: The hospital failed to ensure the kitchen area was maintained in a sanitary and hygienic manner. The cumulative effect of these systemic deficient practices resulted in the facility’s failure to meet the requirement for the Condition of Participation for Infection Prevention and Control and Antibiotic Stewardship and provide a safe environment for patients to protect them from harm.”

“LICENSURE OF HOSPITAL CFR(s): 482.11(b) The hospital must be - o Licensed; or o Approved as meeting standards for licensing established by the agency of the State or locality responsible for licensing hospitals. This Standard is not met as evidenced by: 43788 Based on review of documents, Arizona Revised Statute, Arizona Administrative Code, Arizona Department of Health Medical Facilities Licensing Files, Phoenix Fire Code, observation and interview, it was determined the hospital: 1 . failed to ensure the hospital had obtained proper licensing for the kitchen used to prepare patient food. 2. failed to ensure the fire alarm system was inspected and maintained in accordance with the Phoenix Fire Code. 3. provided false and misleading information in the environment of care Immediate Jeopardy Corrective Action Plan by continuing to admit patients to the hospital’s intake area when the hospital was closed to patient admissions until Department approval. These deficient practices pose a risk to the health and safety of patients and staff if services are provided in a location that has not been properly determined to be environmentally and physically safe to provide services which could lead to injury or death. Cross reference A0020, A0043, A0057, A0715 Findings include: 1. Review of the Arizona Revised Statute A.R.S.36-421. Construction or modification of a health care institution revealed: “...A. A license application for a health care institution shall include, on a form provided by the department, a notarized attestation from an architect registered pursuant to title 32, chapter 1 that verifies the architectural plans and specifications meet or exceed standards adopted by the department. These plans and specifications shall meet the minimum standards for licensure within the class or subclass of health care institution for which it is intended. The application shall include the name and address of each owner and lessee of any agricultural land that is regulated pursuant to section 3-365 ...B. Construction or modification of a licensed health care institution shall meet the minimum standards for licensure within the class or subclass of health care institution for which it is intended ...C. An applicant shall comply with all state statutes and rules and local codes and ordinances required for the health care institution’s construction ....” Review of Arizona Administrative Code R9-10-104 Approval of Architectural Plans and Specifications revealed: “...A. For approval of architectural plans and specifications for the construction or modification of a health care institution that is required by this Chapter to comply with any of the physical plant codes and standards incorporated by reference in R9-10-104.01, an applicant shall submit to the Department an application packet including: b. For modification of a licensed health care institution that requires approval of architectural plans and specifications:i. The health care institution’s license number,ii. The name and mailing address of the licensee,iii. The health care institution’s class or subclass, and iv. The health care institution’s existing licensed capacity, licensed occupancy, respite capacity, or number of dialysis stations; and the requested licensed capacity, licensed occupancy, respite capacity, or number of dialysis stations for the health care institution; e. A narrative description of the project; k. A statement signed by the governing authority or the licensee that the architectural plans and specifications comply with applicable licensing requirements in A.R.S. Title 36, Chapter 4 and this Chapter; 2. If the health care institution is located on land under the jurisdiction of a local governmental agency, one of the following:a. A building permit for the construction or modification issued by the local governmental agency; or 3. The following information that is as necessary to demonstrate that the project described on the application complies with applicable codes and standards incorporated by reference in R9-10-104.01:a. A table of contents containing:i. The architectural plans and specifications submitted;ii. The physical plant codes and standards incorporated by reference in R9-10-104.01 that apply to the project;iii. The physical plant codes and standards that are required by a local governmental agency, if applicable; 5. The following, as applicable: b. A certification and a statement that the construction or modification of the facility is in substantial compliance with applicable licensing requirements in A.R.S. Title 36, Article 4 and this Chapter signed by the project architect, the contractor, and the owner;c. A written description of any work necessary to complete the construction or modification submitted by the project architect ....” Review of the facility ’ s Arizona Department of Health Medical Facilities Licensing file revealed no evidence of the facility submitting a Modification Application Packet for the Kitchen. Further review of the facility ’ s licensing file revealed an attachment dated 04/21/2022 labeled “kitchen addition to licensed space”. Review of this attachment revealed a floor plan highlighting a kitchen area in a building adjacent to the facility. Also highlighted on the floor plan was an area that appeared to be a long hallway that connected the kitchen in the adjacent building to the facility. The kitchen area in the adjacent building and the adjacent building do not share a contiguous space with the facility. Also included with the floor plan was a document labeled Functional Space Program-Food & Nutrition Department. Review of this document revealed a plan to operate a Food Services Department on site at the facility. Further review of the facility ’ s licensing file revealed no evidence of a modification approval survey being conducted by licensing officers. Further review revealed no evidence of a post survey Department approval letter permitting the facility to utilize the kitchen space for food services at the facility. A request was made for a copy of a modification application for the kitchen. None was provided. A request was made for a copy of the entrance letter for the modification survey for the kitchen. None was provided. A request was made for a copy of the post survey Department approval letter. None was provided. Observation while on tour of the facility revealed the kitchen area was in a former non-operational hospital next door to the facility. Further observation revealed that the highlighted area on the above mentioned floor plan that appeared to be a long hallway was in fact, an underground tunnel connecting the facility to the non-operational hospital. Employee #4 confirmed on 08/06/2024 that the kitchen area was in another building and food was being transported to the facility from the kitchen area on carts through the underground tunnel. Employee #2 confirmed on 08/06/2024 that the facility was utilizing the kitchen area in the non-operational hospital next door to the facility. Employee #2 confirmed a modification application packet had not been submitted to the Department. 2. A request was made for the hospital’s current fire inspection. None was provided. A request was made to the Phoenix Fire Department for the hospital’s current fire inspection. A fire inspection report dated 10/06/2023 was provided by the Phoenix Fire Department. Document titled, “City of Phoenix Fire Prevention Notice of Non-Compliance”, dated 10/06/2023 revealed: “...All Fire Code References are Phoenix City Code §15. · Code Title #1: PFC901.6 Inspection, testing and maintenance. Code Text #1: Fire detection and alarm systems, emergency alarm systems, gas detection systems, fire-extinguishing systems, smoke control systems, mechanical smoke exhaust systems, and smoke and heat vents shall be maintained in an operative condition at all times, and shall be replaced or repaired where defective. Nonrequired fire protection systems shall be inspected and tested by a contractor licensed by the State of Arizona who is a current qualified contractor by the Phoenix Fire Department to work on the particular fire protection system being inspected or tested in accordance with NFPA standards, see Section 108.1. It shall be the responsibility of the owner to ensure that these requirements are met. Non-Compliant Condition #1: The fire pump has a reported deficiency on the most recent fire servicing report. Correction Required #1: The fire pump system shall be inspected and maintained in accordance with the Phoenix Fire Code...Obtain system signoffs (Green tags) for each system repaired or corrected. Required Compliance Date #1: 10/06/2023. Violation Corrected #1 In compliance on #1: NO · Code Title #2: PFC901.6 Inspection, testing and maintenance. Code Text #2: Fire detection and alarm systems, emergency alarm systems, gas detection systems, fire-extinguishing systems, smoke control systems, mechanical smoke exhaust systems, and smoke and heat vents shall be maintained in an operative condition at all times, and shall be replaced or repaired where defective. Nonrequired fire protection systems shall be inspected and tested by a contractor licensed by the State of Arizona who is a current qualified contractor by the Phoenix Fire Department to work on the particular fire protection system being inspected or tested in accordance with NFPA standards, see Section 108.1. It shall be the responsibility of the owner to ensure that these requirements are met. Non-Compliant Condition #2: The fire alarm system has reported deficiencies on the most recent fire servicing report. Correction Required #2: The fire alarm system shall be inspected and maintained in accordance with the Phoenix Fire Code...Obtain system signoffs (Green tags) for each system repaired or corrected. Required Compliance Date #2: 10/06/2023. Violation Corrected #2 In Compliance on #2: NO · Code Title #3: PFC901.6 Inspection, testing and maintenance. Code Text #3: Fire detection and alarm systems, emergency alarm systems, gas detection systems, fire-extinguishing systems, smoke control systems, mechanical smoke exhaust systems, and smoke and heat vents shall be maintained in an operative condition at all times, and shall be replaced or repaired where defective. Nonrequired fire protection systems shall be inspected and tested by a contractor licensed by the State of Arizona who is a current qualified contractor by the Phoenix Fire Department to work on the particular fire protection system being inspected or tested in accordance with NFPA standards, see Section 108.1. It shall be the responsibility of the owner to ensure that these requirements are met. Non-Compliant Condition #3: The kitchen hood system is past due for its annual inspection, testing, and maintenance. Correction Required #3: The kitchen hood system shall be inspected and maintained in accordance with the Phoenix Fire Code...Obtain system signoffs (Green tags) for each system repaired or corrected. Required Compliance Date #3: 10/06/2023. Violation Corrected #3 In Compliance on #2: NO....” Review of document titled, “City of Phoenix Fire Department Fire Prevention”, revealed: “...As noted in the Notice of Non-Compliance (N.O.N.C.) issued on October 6, 2023, several violations were identified that require immediate attention...Although the patients have been evacuated due to the inoperability of your chillers, your staff remains on-site. To ensure their safety and permit continued staff occupancy, the following actions must be implemented immediately: 1. Unlock All Egress Doors: All egress doors must be unlocked to ensure free and unobstructed ext for all personnel working in the building. 2. Implement A Fire Watch: A two-person fire watch is required,one for each building. In the absence of a functional fire alarm system, fire watch personnel must be designated to monitor fires and notify others in the event of an emergency. These individuals should be able to communicate effectively with each other and contact emergency services (911) if necessary. Due to these outstanding fire protection issues, your operational permit has been temporarily revoked. In order to reinstate the permit and allow for occupancy of patients in the future, please address the following: 1. Restore Fire Alarm System: The fire alarm system in the Behavioral Health Center (BHC) must be fully operational. 2. Submit Evacuation Procedures: Provide detailed evacuation procedures to the fire department for review and consideration....” Employee #4 confirmed that a copy of a current fire inspection was not available. 3. Document titled, “Immediate Corrective Action Plan Environment of Care”, dated 08/09/2024 revealed: “...Need for immediate evacuation of all patients...SLBHC had been working closely SLBHC has been working closely with AHCCCS, Mercy Care, Arizona Complete, Molina Healthcare, AMR, and AZCHER. SLBHC has transferred 76 patients since the onset of this event on the evening of 8/8/24. Families and guardians were notified prior to transfers being completed. Patients were transferred with necessary medical information to facilitate a safe transition. 27 patients remain in the building as of this time. 11 of those 27 have been accepted for transfer and are in the process of being moved. 18 patients remain without an accepting facility, and 11 of those are adolescent (minor) patients. As of this afternoon [Dr. Salek,] Medical Director of AHCCCS, and [Dr. Singh] from Mercy Care have been on site and assisting with the placement of the remaining 29 patients. Efforts will continue until the last patient is transferred. The AZ Department of Health Services will be notified immediately when the last patient is placed and the building is closed. The AZ Department of Health Services will be immediately notified when temperatures are back within normal range and the organization is ready to accept patients....” Upon arrival to the hospital on 08/12/2024 at 10:00 am, compliance officers performed temperature checks throughout the entire hospital and found temperatures to be above the acceptable range of 70-75 degrees F in most patient care area and the hospital lobby. Temperatures were noted to be 89 degrees F in the lobby and 90.5 degrees in the intake area of the hospital. Observation upon arrival to the hospital on 08/12/2024 at 10:00 am, revealed an individual in a wheelchair in the intake area talking with a hospital staff member. Employee #11 confirmed on 08/12/2024 that the individual in the wheelchair in the intake area was a walk-in patient. Employee #11 confirmed all inpatient patients had been discharged, however, the hospital was still admitting patients to the intake area for assessment and evaluation. Employee #11 stated that once the determination was made that the patient would need inpatient treatment the hospital would arrange a transfer to an accepting facility. Employee #11 confirmed the hospital’s temperatures remained outside the normal range. Employee #3 confirmed on 08/12/2024 that the hospital’s temperatures remained out of range and the Department had not approved the hospital to admit patients. Employee #3 confirmed the hospital was still admitting patients to the intake area for assessment and evaluation. Employee #41 confirmed on 08/12/2024 that the hospital was accepting walk-in patients for assessment and evaluation despite the hospital being closed due to the HVAC system failure and the hospital’s temperatures being out of the normal range. Employee #41 confirmed the patient in the intake area on 08/12/2024 was in an area of the hospital where the temperatures remained out of range. Employee #41 confirmed the Department had not given approval for the hospital to begin admitting patients.”

“CHIEF EXECUTIVE OFFICER CFR(s): 482.12(b) The governing body must appoint a chief executive officer who is responsible for managing the hospital. This Standard is not met as evidenced by: 43788 Based on review of documents, observations, and interviews, it was determined the Chief Executive Officer (CEO) failed to manage the daily operation of the hospital. This deficient practice poses a risk to the health and safety of patients when leadership does not provide proper guidance, enforcement of policies and procedures and provide resources to provide care to meet the needs of patients. Findings include: Review of Employee #41 job description “Arizona Regional President” revealed: “...oversee operations and leadership at all of Steward’s Arizona health care facilities, including Mountain Vista Medical Center, Tempe St. Luke’s Hospital,St. Luke’s Behavioral Hospital and Florence Hospital....” It was determined the CEO/Regional President failed to manage to manage the day-to-day operations of the hospital as demonstrated by the following: A0020: The hospital failed to comply with state and local laws and regulations required for licensure. (Cross reference A0022, A0043) A0022: The hospital: 1 . failed to ensure the hospital had obtained proper licensing for the kitchen used to prepare patient food. 2. failed to ensure the fire alarm system was inspected and maintained in accordance with the Phoenix Fire Code. 3. provided false and misleading information in the environment of care Immediate Jeopardy Corrective Action Plan by continuing to admit patients to the hospital’s intake area when the hospital was closed to patient admissions until Department approval. (Cross reference A0020, A0043, A0715) A0168: The hospital failed to ensure an order was made before restraint/seclusion was initiated. (Cross reference A0043) A0273: The hospital failed to ensure an incident report was completed for allegation of abuse for a patient (Patient #20). (Cross reference A0043) A0392: The hospital failed to ensure there were sufficient numbers of nursing staff to provide patient care according to hospital acuity plan. (Cross reference A0043) A0618: The hospital failed to provide organized dietary services to meet the nutritional needs of the patients in a sanitary and hygienic environment. (Cross reference A0043, A0619, A0700, A0747, A0750) A0619: The hospital failed to ensure: 1.kitchen staff wore hair nets; 2. the kitchen, kitchen carts, shelves, and equipment were cleaned, disinfected, and maintained; 3. refrigerator and freezer temperatures were monitored and interventions implemented for out of range readings;and 4. expired and outdated food products were discarded and not available for consumption; 5. food was stored appropriately in a clean and sanitary manner; and; 6. food temperatures were monitored and interventions implemented for out of range readings; (Cross reference A0043, A0618, A0700, A0747, A0750) A0700: The Hospital failed to maintain the physical environment of the hospital to protect the health and safety of patients. (Cross reference A0020, A0022, A0043, A0618, A0619, A0701, A0715, A0724, A0747, A0750) A0701: The Governing Body and the Hospital failed to ensure the facility was adequately maintained by: 1. failing to ensure kitchen equipment was maintained and operational. 2. failing to ensure HVAC System was maintained and operational. 3. failing to ensure fire alarms were maintained and operational. 4. failing to ensure elevators were maintained and operational. 5. failing to ensure plumbing leaks and drainage pipes were maintained and operational. (Cross reference A0020, A0022, A0043, A0618, A0619, A0700, A0715, A0724) A0715: The hospital failed to ensure fire alarms were maintained. (Cross reference A0020, A0022, A0043, A0700, A0701) A0724: The hospital failed to ensure the HVAC system was maintained in working order. (Cross reference A0020, A0022, A0043, A0700, A0701, A0715) A0747: The failed to meet the Conditions of Participation by failing to maintain and monitor the sanitary and hygienic environment of the kitchen. (Cross reference 43, A0618, A0619, A0750) A0750: The hospital failed to ensure the kitchen area was maintained in a sanitary and hygienic manner. (Cross reference A0043, A0618, A0619, A0747) Employee #3 confirmed on 08/12/2024 that he was the CEO and responsible for the management of the hospital. Employee #3 confirmed that Employee #41 was the Regional President and oversees all Steward owned facilities in Arizona.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 50979 Based on record reviews,it was determined the hospital failed to ensure an order was made before restraint/seclusion was initiated. This deficient practice poses a health and safety risk to patients bring placed in restraints/seclusion without a physician order. Findings: Policy titled “Seclusion/Restraint” revealed, “ ...Definitions ...Behavioral Emergency: A situation involving a patient who is behaving in a violent or self-destructive manner and in which preventive, de-escalating or verbal techniques have been determined to be ineffective and it is immediately necessary to restrain or seclude the patient to prevent: ...Imminent physical harm to others because of aggressive behavior ...A physician or other LP responsible for the care of the patient will order restraint or seclusion prior to the application or restraint or seclusion. In some situations, however, the need for a restraint or seclusion intervention may occur so quickly that an order cannot be obtained prior to the application of restraint or seclusion. In these emergency application situation, the order must be obtained either during emergency ...or immediately (within a few minutes) after ...When ONLY one staff is using a personal restraint/physical hold, ...a second staff member ...shall maintain 1:1 observation of the patient ...” Patient #20’s medical record revealed, “ ...Other Note ...At about 2045hr RN went into patients room to give medications. TW also went into patients room due to patient being highly aggressive towards staff. When RN went to give medications, the patient that he did not want to take the medications. RN informed patient that he did not take the medications due to being COT an injection would have to be administered. Patient grabbed the medications from RN and put them in his mouth, the patient then yanked the water cup from the RN causing the cup to drop to the floor. RN asked patient to get up and go get some more water. Patient then lunged at RN. RN had to hold patient due to no other tech available to help RN control patient. Patient was trying to assault RN by hitting him/her. Patient and RN fell on floor. Other tech got to patient room and assisted RN with controlling patient ...” Dated 07/21/22 20:50. Patient #20’s medical record revealed, “ ...Nurse Note ...This writer at about 2045 went into patients room to give medications. Pt got aggressive verbally calling this writer as well as a standing BHT all sorts of profane derogatory names although he grabbed the meds in a motion of taking them s/he yanked the water cup out of writers hand. The water spilled. Writer explained to patient that he had to take the meds of get some injections as part of the recommended treatment plan. Patient got very aggressive towards this writer and struck writer on the neck area. This writer held onto patient and fell to the floor with Patient until help came in. Patient was given injections since he eventually spit out the meds. Will continue to monitor patients aggressive behavior ...” Dated 07/21/22 21:57. Other documentation revealed, “ ...Seclusion & Restraint Report to RHBA ...Type ...Personal/Physical Restraint Start: 2045 Stop: 2055 ...Mins: 10mins ...Reason for Restraint/Seclusion ...(DTO) ...Patient agitated and aggressive Patient hit the writer Patient was held to avoid further injury until other staff member could respond to the scene ...Was the patient injured during the restraint/seclusion?...minor skin tear/abrasion to R facial area ...Discontinue Restraint/Seclusion ...Pt responsive to redirection and resting in at this time ...” Other documentation revealed, “ ...There was an incident on 7/21/22 regarding Patient #20. The patient was agitated and upset at the nurse who was trying to give him/her in medications. Patient took his medications, hit the cup of water out of nurse’s hand and tried to hit the nurse in the upper chest area. Nurse put patients in a physical hold until a code was called, and other staff members arrived. Patient spit out his/her medications and refused to take them. The nurse failed in this situation to notify the provider of this incident and so order for the physical hold was not given by the provider. The Nurse involved in this situation has been disciplined for this action ...” Employee #12 confirmed restraint/seclusion was initiated upon on Patient #20 without a provider order.”

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 50979 Based on record reviews and staff interviews, it was determined the hospital failed to ensure an incident report was completed for allegation of abuse for a patient (Patient #20). This deficient practice poses a risk to the health and safety of patients if incident reports are not completed to track and trend patterns to identify improvement opportunities. Findings include: Policy titled “Incident Reporting” revealed, “ ...Purpose ...The goal of effective incident management is to minimize the likelihood of reoccurrence and hence build a more resilient safety system. Every incident will activate an appropriate investigation and response ...Definitions ...Incident: An undesirable and unexpected event, which has an actual, potential or perceived adverse impact on a patient or visitor ...Reportable Event: a serious clinical or operational incident that must be reported to regulating agencies ...Investigation/Followup/Recommendation ...When an incident report is completed, it is directed to the risk manager ...All incidents will be finalized with final severity, injury, and appropriate corrective actions ...” Patient #20’s medical record revealed, “ ...Other Note ...At about 2045hr RN went into patients room to give medications. TW also went into patients rom due to patient being highly aggressive towards staff. When RN went to give medications, the patient that he did not want to take the medications. RN informed patient that he did not take the medications due to being COT an injection would have to be administered. Patient grabbed the medications from RN and put them in his mouth, the patient then yanked the water cup from the RN causing the cup to drop to the floor. RN asked patient to get up and go get some more water. Patient then lunged at RN. RN had to hold patient due to no other tech available to help RN control patient. Patient was trying to assault RN by hitting him/her. Patient and RN fell on floor. Other tech got to patient room and assisted RN with controlling patient ...” Dated 07/21/22 20:50. Patient #20’s medical record revealed, “ ...Nurse Note ...This writer at about 2045 went into patients room to give medications. Pt got aggressive verbally calling this writer as well as a standing BHT all sorts of profane derogatory names although he grabbed the meds in a motion of taking them s/he yanked the water cup out of writers hand. The water spilled. Writer explained to patient that he had to take the meds of get some injections as part of the recommended treatment plan. Patient got very aggressive towards this writer and struck writer on the neck area. This writer held onto patient and fell to the floor with Patient until help came in. Patient was given injections since he eventually spit out the meds. Will continue to monitor patients aggressive behavior ...” Dated 07/21/22 21:57 Patient #20’s medical record revealed, “ ...Nurse Note ...Patient was complaint with medications, received LAI this shift. Pt has several abrasions from physical altercation with staff the previous night. Per out going shift, pt refused oral meds and physically assaulted RN giving meds. Pt’s ...guardian called for updates and is willing to answer questions on medications and previous behaviors ...” Dated 07/22/22. Other documentation revealed, “ ...There was an incident on 7/21/22 regarding Patient #20. The patient was agitated and upset at the nurse who was trying to give him/her in medications. Patient took his medications, hit the cup of water out of nurse’s hand and tried to hit the nurse in the upper chest area. Nurse put patients in a physical hold until a code was called, and other staff members arrived. Patient spit out his/her medications and refused to take them. The nurse failed in this situation to notify the provider of this incident and so order for the physical hold was not given by the provider. The Nurse involved in this situation has been disciplined for this action ...” Interview with Employee #12 revealed an Incident Report dated 7/21/22. Investigation included in-person follow up, email follow up, and camera review. Resolution was education and to notify APS and DMH. Comments was filed out and indicated BHT that responded to scene confirmed to physical abuse Patient #20. BHT was asked to leave scene. Patient #20 injury was indicated from physical restraint and not physical abuse from BHT. Interview with Employee #12 revealed the comments in Incident Report dated 7/21/22 should have been reported as a separate Incident Report.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 48110 Based on record reviews and staff interviews, it was determined the hospital failed to ensure there were sufficient numbers of nursing staff to provide patient care according to hospital acuity plan. This deficient practice poses a risk to the health and safety of patients when there is insufficient staff on the units to meet patient needs, and resulting in inadequate monitoring of patients. Findings include: Hospital policy titled, “Inpatient Staffing/Acuity Plan and Patient Acuity Tool Guidelines”, revealed: “ ...Policy: A. It is the policy of this hospital to ensure the appropriate number and skill mix of nursing personnel needed for each unit is determined after a registered nurse’s evaluation of the patients’ acuity level, unit activities, admissions and discharges ....Procedure: ...4. An acuity rating for each patient is performed each shift at the designated time to project and facilitate the care needs and care requirements of the patients for the oncoming shift based on treatment plan, observations, activities, interventions and assessment information related to each patient ....B. Staffing Matrix: 1. On the day and evening shifts the maximum patient RN ratio is 15:1 ...3. On the day and evening shift the maximum patient to BHT ratio is 15:1 on the adult units and 15:1 for children and adolescent units ....A. Any identified concerns relating to the acuity based staffing guidelines will be communicated to the House Supervisor, Nurse Managers, or the Chief Nursing Officer at least 2 hours prior to the start of the next shift ....B. The hospital shall take all reasonable steps to assure that there are sufficient numbers of qualified nursing staff members available at all times to meet the nursing care needs of patients in all applicable units and areas ....Acuity Based Staffing Guidelines ....AP1 ...Days 0700-1930 ...(down arrow) - 28 points ...1 RN 1 BHT ...29-40 points ...1 RN 2 BHT ...41-55 points ...2 RN 3 BHT ...56-70 points ...3 RN 3 BHT ...71 or more points ...3 RN 4 BHT ...Nights 1900-0730 ...(down arrow) - 28 points ...1 RN 1 BHT ...29-40 points ...1 RN 2 BHT ...41-55 points ...2 RN 2 BHT ...56-70 points ...2 RN 3 BHT ...71 or more points ...2 RN 3 BHT ....AP2 ...Days 0700-1930 ...(down arrow) - 28 points ...1 RN 1 BHT ...29-40 points ...2 RN 2 BHT ...41-55 points ...2.5 RN 2 BHT ...56-70 points ...3 RN 3 BHT ...71 or more points ...3 RN 4 BHT ... Nights 1900-0730 ...(down arrow) - 28 points ...1 RN 1 BHT ...29-40 points ...2 RN 1 BHT ...41-55 points ...2 RN 2 BHT ...56-70 points ...2 RN 2 BHT ...71 or more points ...2 RN 2 BHT ....AP3 ... Days 0700-1930 ...(down arrow) - 28 points ...1 RN 1 BHT ...29-40 points ...2 RN 2 BHT ...41-55 points ...2.5 RN 2 BHT ...56 or more ...2.5 RN 3 BHT ...Nights 1900-0730 ...(down arrow) - 28 points ...1 RN 1 BHT ...29-40 points ...2 RN 2 BHT ...41-55 points ...2 RN 2 BHT ...56 or more ...2 RN 2 BHT ... AP4 ... Days 0700-1930 ...(down arrow) - 28 points ...1 RN 2 BHT ...29-40 points ...2 RN 2 BHT ...41 or more ...2 RN 3 BHT ...Nights 1900-0730 ...(down arrow) - 28 points ...1 RN 2 BHT ...29-40 points ...2 RN 2 BHT ...41 or more ...2 RN 2 BHT ... AP5 ... Days 0700-1930 ...(down arrow) - 28 points ...1 RN 2 BHT ...29-40 points ...2 RN 2 BHT ...41-55 points ...2 RN 3 BHT ...56-70 ...3 RN 4 BHT ...71 or more points ...3 RN 5 BHT ...Nights 1900-0730 ...(down arrow) - 28 points ...1 RN 1 BHT ...29-40 points ...2 RN 2 BHT ...41-55 points ...2 RN 3 BHT ...56-70 points ...2 RN 3 BHT ...71 or more points ...2 RN 3 BHT ...CAS ...Days 0700-1930 ...(down arrow) - 28 points ...1 RN 2 BHT ...29-40 points ...2 RN 2 BHT ...41-55 points ...2 RN 3 BHT ...56-70 points ...3 RN 4 BHT ...71 or more points ...3 RN 5 BHT ...Nights 1900-0730 ...(down arrow) - 28 points ...1 RN 1 BHT ...29-40 points ...2 RN 2 BHT ...41-55 points ...2 RN 3 BHT ...56-70 points ...2 RN 4 BHT ...71 or more points 2 RN 4 BHT ....” Staffing sheets on day shift of 12/17/2023 revealed: AP1 acuity of 56 with two RN and three BHT, missing one RN AP5 acuity of 70 with three RN and three BHT, missing two BHT CAS acuity of 76 with two RN and four BHT, missing one RN and one BHT Staffing sheets on night shift of 12/17/2023 revealed: AP2 acuity of 42 with two RN and one BHT, missing one BHT AP5 acuity of 77 with two RN and two BHT, missing one BHT CAS acuity of 78 with two RN and three BHT, missing one BHT Staffing sheets on day shift of 12/18/2023 revealed: AP2 acuity of 50 with two RN and two BHT, missing 0.5 RN Staffing sheets on day shift of 12/19/2023 revealed: AP3 acuity of 32 with one RN and two BHT, missing one RN Staffing sheets on night shift of 12/19/2023 revealed: AP2 acuity of 36 with one RN and two BHT, missing one RN AP4 acuity of 34 with one RN and two BHT, missing one RN CAS acuity of 82 with two RN and two BHT, missing two BHT Staffing sheets on day shift of 12/20/2023 revealed: AP1 acuity of 61 with two RN and four BHT, missing one RN AP3 acuity of 36 with one RN and two BHT, missing one RN AP4 acuity of 30 with one RN and two BHT, missing one RN CAS acuity of 71 with three RN and three BHT, missing two BHT Staffing sheets on day shift of 12/21/2023 revealed: AP1 acuity of 63 with two RN and four BHT, missing one RN AP2 acuity of 43 with one RN and three BHT, missing 1.5 RN AP3 acuity of 43 with one RN and two BHT, missing 1.5 RN AP4 acuity of 40 with one RN and two BHT, missing one RN AP5 acuity of 72 with three RN and three BHT, missing two BHT CAS acuity of 71 with two RN and three BHT, missing one RN and two BHT Staffing sheets on night shift of 12/21/2023 revealed: AP1 acuity of 69 with two RN and four BHT, missing one RN AP4 acuity of 36 with one RN and two BHT, missing one RN CAS acuity of 71 with two RN and three BHT, missing one BHT Staffing sheets on day shift of 12/22/2023 revealed: AP3 acuity of 6 with one BHT, missing one RN Staffing sheets on night shift of 12/22/2023 revealed: AP4 acuity of 40 with one RN and two BHT, missing one RN Staffing sheets on night shift of 12/23/2023 revealed: AP4 acuity of 29 with one RN and two BHT, missing one RN AP5 acuity of 67 with two RN and two BHT, missing one BHT CAS acuity of 58 with two RN and two BHT, missing two BHT Staffing sheets on day shift of 12/24/2023 revealed: AP2 acuity of 61 with two RN and three BHT, missing one RN Staffing sheets on night shift of 12/24/2023 revealed: AP4 acuity of 30 with one RN and two BHT, missing one RN Staffing sheets on day shift of 12/25/2023 revealed: AP5 acuity of 68 with two RN and five BHT, missing one RN Staffing sheets on night shift of 12/25/2023 revealed: AP1 acuity of 55 with one RN and three BHT, missing one RN AP5 acuity of 67 with one RN and three BHT, missing one RN CAS acuity of 54 with one RN and three BHT, missing one RN Staffing sheets on day shift of 12/26/2023 revealed: AP4 acuity of 36 with one RN and two BHT, missing one RN Staffing sheets on night shift of 12/26/2023 revealed: AP1 acuity of 64 with one RN and three BHT, missing one RN AP4 acuity of 33 with one RN and two BHT, missing one RN AP5 acuity of 64 with one RN and three BHT, missing one RN CAS acuity of 56 with one RN and four BHT, missing one RN Staffing sheets on day shift of 12/27/2023 revealed: AP4 acuity of 40 with one RN and two BHT, missing one RN AP5 acuity of 63 with three RN with one RN leaving at 1100, and three BHT, missing one RN and one BHT Staffing sheets on night shift of 12/27/2023 revealed: AP4 acuity of 39 with one RN and two BHT, missing one RN Staffing sheets on day shift of 12/28/2023 revealed: AP2 acuity of 66 with three RN and three BHT, missing one RN AP4 acuity of 30 with one RN and two BHT, missing one RN Staffing sheets on day shift of 12/29/2023 revealed: AP1 acuity of 62 with two RN and three BHT, missing one RN Staffing sheets on day shift of 12/30/2023 revealed: AP1 acuity of 57 with two RN and three BHT, missing one RN AP2 acuity of 43 with two RN and two BHT, missing 0.5 RN AP5 acuity of 56 with two RN and three BHT, missing one RN and one BHT CAS acuity of 41 with two RN and two BHT, missing one BHT Staffing sheets on night shift of 12/30/2023 revealed: AP4 acuity of 28 with one RN and one BHT, missing one BHT AP5 acuity of 64 with two RN and two BHT, missing one BHT CAS acuity of 44 with two RN and two BHT, missing one BHT Staffing sheets on night shift of 01/07/2024 revealed: AP4 acuity of 42 with one RN and two BHT, missing one RN AP5 acuity of 69 with two RN and two BHT, missing one BHT CAS acuity of 61 with two RN and four BHT with two BHT leaving at 2100. Staffing sheets on day shift of 01/08/2024 revealed: AP2 acuity of 74 with two RN and three BHT, missing one RN and one BHT AP3 acuity of 49 with two RN and two BHT, missing 0.5 RN AP5 acuity of 69 with two RN and four BHT, missing one RN CAS acuity of 65 with one RN and five BHT, missing two RN Staffing sheets on night shift of 01/08/2024 revealed: AP1 acuity of 58 with one RN and three BHT, missing one RN AP3 acuity of 50 with one RN and one BHT, missing one RN and one BHT AP4 acuity of 44 with one RN and one BHT, missing one RN and one BHT CAS acuity of 61 with one RN and five BHT, missing one RN Staffing sheets on day shift of 01/09/2024 revealed: AP2 acuity of 62 with two RN and three BHT, missing one RN AP3 acuity of 45 with two RN and two BHT, missing 0.5 RN AP5 acuity of 66 with two RN and four BHT, missing one RN CAS acuity of 69 with two RN and three BHT, missing one RN and one BHT Staffing sheets on night shift of 01/09/2024 revealed: AP3 acuity of 45 with one RN and two BHT with one BHT leaving at 2300, missing one RN AP4 acuity of 32 with one RN and two BHT, missing one RN CAS acuity of 61 with two RN with one leaving at 2300, and three BHT, missing one RN and one BHT Staffing sheets on day shift of 01/10/2024 revealed: AP2 acuity of 53 with two RN and two BHT, missing 0.5 RN AP5 acuity of 71 with three RN and four BHT, missing one BHT CAS acuity of 71 with two RN and five BHT, missing one RN Staffing sheets on night shift of 01/10/2024 revealed: AP4 acuity of 30 with one RN and two BHT, missing one RN Staffing sheets on day shift of 01/11/2024 revealed: AP2 acuity of 43 with two RN with one arriving at 1100 and other leaving at 1500, and two BHT, missing 1.5 RN AP3 acuity of 37 with one RN and two BHT, missing one RN AP4 acuity of 33 with one RN and two BHT, missing one RN AP5 acuity of 68 with two RN and four BHT, missing one RN CAS acuity of 71 with three RN with one RN leaving at 1130, and four BHT, missing one RN and one BHT Staffing sheets on night shift of 01/11/2024 revealed: AP2 acuity of 35 with one RN and two BHT, missing one RN AP4 acuity of 34 with one RN and two BHT, missing one RN Staffing sheets on day shift of 01/12/2024 revealed: AP5 acuity of 67 with two RN and four BHT with one leaving at 1100, missing one RN and one BHT Staffing sheets on day shift of 01/13/2024 revealed: AP2 acuity 41 with one RN and two BHT, missing 1.5 RN AP5 acuity 67 with three RN with one leaving at 1015, and four BHT, missing one RN after 1015 Staffing sheets on night shift of 01/13/2024 revealed: AP4 acuity 32 with one RN and two BHT, missing one RN Staffing sheets on day shift of 01/14/2024 revealed: AP1 acuity 56 with two RN and three BHT, missing one RN AP4 acuity 31 with one RN and three BHT, missing one RN Staffing sheets on night shift of 01/14/2024 revealed: AP1 acuity 56 with one RN and three BHT, missing one RN AP5 acuity 73 with two RN and two BHT, missing one BHT CAS acuity 69 with two RN and four BHT with one leaving at 2300, missing one BHT after 2300 Staffing sheets on day shift of 01/15/2024 revealed: AP3 acuity 48 with one RN and two BHT, missing 1.5 RN CAS acuity 73 with two RN and four BHT, missing one RN and one BHT Staffing sheets on night shift of 01/15/2024 revealed: AP3 acuity 43 with one RN and one BHT, missing one RN and one BHT AP4 acuity 35 with one RN and two BHT with one leaving at 2300, missing one RN and one BHT after 2300 Staffing sheets on day shift of 01/16/2024 revealed: AP2 acuity 82 with two RN and four BHT, missing one RN AP3 acuity 32 with one RN and two BHT, missing one RN AP5 acuity 67 with two RN and four BHT, missing one RN CAS acuity 68 with two RN and four BHT, missing one RN Staffing sheets on night shift of 01/16/2024 revealed: AP3 acuity 33 with two RN with one leaving at 2030, and two BHT, missing one RN after 2030 AP4 acuity 42 with one RN and two BHT, missing one RN Staffing sheets on day shift of 01/17/2024 revealed: AP2 acuity 64 with two RN and three BHT, missing one RN AP3 acuity 30 with one RN and two BHT, missing one RN CAS acuity 62 with three RN and three BHT, missing one BHT Staffing sheets on night shift of 01/17/2024 revealed: AP3 acuity 36 with one RN and two BHT, missing one RN AP4 acuity 37 with one RN and two BHT, missing one RN Staffing sheets on day shift of 01/18/2024 revealed: AP1 acuity 56 with two RN and three BHT, missing one RN AP2 acuity 73 with two RN and two BHT, missing one RN and two BHT AP3 acuity 40 with two RN and one BHT, missing one BHT AP4 acuity 41 with two RN and two BHT, missing one BHT AP5 acuity 67 with two RN and four BHT, missing one RN Staffing sheets on night shift of 01/18/2024 revealed: AP3 acuity 40 with one RN and two BHT, missing one RN Staffing sheets on day shift of 01/19/2024 revealed: AP1 acuity 58 with two RN and three BHT, missing one RN AP2 acuity 72 with two RN and two BHT, missing one RN and two BHT AP3 acuity 40 with one RN and one BHT, missing one RN and one BHT AP4 acuity 41 with one RN and two BHT, missing one RN and one BHT AP5 acuity 63 with three RN and three BHT, missing one BHT CAS acuity 81 with three RN and four BHT, missing one BHT Staffing sheets on night shift of 01/19/2024 revealed: AP2 acuity 70 with one RN and two BHT, missing one RN AP4 acuity 42 with one RN and two BHT, missing one RN Staffing sheets on day shift of 01/20/2024 revealed: AP1 acuity 56 with two RN and four BHT, missing one RN AP2 acuity 37 with two RN with one leaving at 1100, and three BHT, missing one RN after 1100 AP3 acuity 40 with one RN and two BHT, missing one RN AP5 acuity 65 with two RN and three BHT, missing one RN and one BHT CAS acuity 75 with two RN and four BHT, missing one RN and one BHT Staffing sheets on night shift of 01/20/2024 revealed: AP2 acuity 42 with one RN and two BHT, missing one RN AP3 acuity 32 with one RN and two BHT, missing one RN AP4 acuity 52 with one RN and two BHT, missing one RN AP5 acuity 65 with two RN and two BHT, missing one BHT CAS acuity 79 with two RN and two BHT, missing two BHT Employee #10 confirmed during an interview conducted on 08/08/2024 that the aforementioned dates were not staffed to the Hospital’s acuity plan.”

“ORGANIZATION CFR(s): 482.28(a) Organization This Standard is not met as evidenced by: 43788 Based on policy and procedure, Arizona Administrative Code, United States Food and Drug Administration publication, Food Code: 2017 Recommendations of the United States Public Health Service, observation, and interview, it was determined that the hospital failed to ensure: 1. kitchen staff wore hair nets; 2. the kitchen, kitchen carts, shelves, and equipment were cleaned, disinfected, and maintained; 3. refrigerator and freezer temperatures were monitored and interventions implemented for out of range readings;and 4. expired and outdated food products were discarded and not available for consumption; 5. food was stored appropriately in a clean and sanitary manner; and; 6. food temperatures were monitored and interventions implemented for out of range readings; The cumulative effect of these deficient practices poses a high potential risk of harm to patients and other individuals who may consume food that was stored and prepared in the facility kitchen in unsanitary equipment and environment if the facility does not follow guidelines set forth in dietary guidelines. Findings include: 1 through 6. The Arizona Administrative Code (9 A.A.C. 8, Article 1) requires: “...ARTICLE 1. FOOD ESTABLISHMENTS...R9-8-101. Purpose and Definitions...A. The Department incorporates by reference the United States Food and Drug Administration publication, Food Code: 2017 Recommendations of the United States Public Health Service, Food and Drug Administration and shall comply with the 2017 Food Code (FC) as specified in this Article. This incorporation by reference contains no future editions or amendments. The incorporated material is on file with the Department and is available for order at: https://www.fda.gov/Food/ResourcesForYou/Consumers/ucm239035.htm, refer to publication number IFS17....” Hospital document titled, “St. Luke ’ s Behavioral Health Hospital 2024 Infection Control Program, Goals, Objectives & Risk Assessment”, revealed: “ ...Goals 12. Ensure food-safety for our patients and staff in order to reduce the risk of transmission of infectious disease via foodborne pathogens ...Food should be received and stored under conditions that maintain nutritional value and minimize the risk of contamination by microorganisms, insects, rodents, and toxic substances ...Records of food and equipment temperatures must be maintained, and remediation steps developed wen systems are not in control ...Corrugated cardboard used to deliver products, should be removed as soon as possible because these boxes may deteriorate or damage the product, the product may leak, or water damage may be present; any moisture rots the boxes, and these conditions allow for pest infestation and possible damage to the product ...Any food left in the refrigerator without a discard date is discarded by the Food Nutrition employee ....” Hospital document titled, “St. Luke ’ s Behavioral Health Center Infection Control & Prevention Meeting Quarterly Meeting Minutes”, dated 04/23/2024 revealed: “ ...Dietary-Kitchen rounds, inspecting from environmental standpoint on cleanliness, check logs for cleaning and ice machine cleaning, logs for temp; will continue to monitor, no issues noted for Dietary ....” 1. The United States Food and Drug Administration publication, Food Code: 2017 Recommendations of the United States Public Health Service, Food and Drug Administration incorporated by reference in subsection (A) from R9-8-101 Food Establishments Purpose and Definition and R9-10-231 Dietary Services requires: “...2-3 PERSONAL CLEANLINESS...2-301 Hands and Arms...2-301.11 Clean Condition...FOOD EMPLOYEES shall keep their hands and exposed portions of their arms clean...Hair Restraints ...2-402.11 ...(A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLESERVICE and SINGLE-USE ARTICLES. (B) This section does not apply to FOOD EMPLOYEES such as counter staff who only serve BEVERAGES and wrapped or PACKAGED FOODS, hostesses, and wait staff if they present a minimal RISK of contaminating exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES....” The FDA Food Code 2017 which is referenced by R9-10-231 1. and R9-8 Article 1 require kitchen staff to wear some type of hair covering or restraint to prevent food from being exposed to hair. Observation while on tour of the kitchen area on 08/07/2024, surveyors were informed that a hairnet was required and donned prior to entering the kitchen prep area. Upon entering the kitchen, surveyors observed two (2) kitchen staff without hairnets in place. Employee #33 confirmed on 08/07/2024 that hairnets were required for anyone entering the kitchen area. Employee #33 confirmed that all staff should have hairnets and confirmed the two (2) staff were not wearing hairnets. 2. The United States Food and Drug Administration publication, Food Code: 2017 Recommendations of the United States Public Health Service, Food and Drug Administration incorporated by reference in subsection (A) from R9-8-101 Food Establishments Purpose and Definition and R9-10-231 Dietary Services requires: “...4-6 CLEANING OF EQUIPMENT AND UTENSILS...4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch....(B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris....” The United States Food and Drug Administration publication, Food Code: 2017 Recommendations of the United States Public Health Service, Food and Drug Administration incorporated by reference in subsection (A) from R9-8-101 Food Establishments Purpose and Definition and R9-10-231 Dietary Services requires: “...6-5 MAINTENANCE AND OPERATION Subpart 6-501 Premises...PHYSICAL FACILITIES shall be maintained in good repair. 6-501.12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. 4-6 CLEANING OF EQUIPMENT AND UTENSILS...4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch....(B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris....” Hospital policy titled, “Equipment Maintenance, Inspection, and Repair”, revealed: “ ...Proper maintenance of the physical plant and all equipment is the FNS Department is the responsibility of the DFNS in cooperation with the Maintenance Department and subject to policies and procedures set forth by the facility ’ s administration ...The DFNS is directed or had knowledge of all routine, periodic, and critical maintenance work done to the physical plant or equipment in the department ...To ensure that all equipment is in safe operating condition, an equipment inspection program is followed ...FNS requests equipment repairs in writing from the Maintenance Department according to established procedures ...Repair to essential equipment are initiated by the Maintenance Department within the agreed upon timeframe ...A preventative maintenance plan should cover: regular inspection/maintenance by the maintenance department; periodic servicing by service companies contracted through the Maintenance Department ...Complete the Equipment Inspection Checklist monthly ...Perform the following checks of each item and any or all supporting parts or connections: visual inspection to determine that the unit is in good condition, is not being used beyond its safe operating limits, and is effectively fulfilling its intended use ...Identify repairs needed ...Monitor completion of repairs ....” Hospital policy titled, “Food and Supply Storage”, revealed: “ ...Mold Prevention: Fix leaky plumbing and leaks in the building envelope as soon as possible; Keep heating, ventilation and air conditioning (HVAC) drip pans clean, flowing properly, and unobstructed ...Clean and dry wet or damp spots within 48 hours ....” Document titled, “Diversey J-512 Sanitizer Use Overview” revealed: J-512 Sanitizer is a no-rinse sanitizer for food contact surfaces. This product is designed for use in dairies, restaurants, bars, and institutions where sanitization is of prime importance ...To sanitize pre-cleaned and portable water-rinsed, non-porous, food contact surfaces, prepare a 200-ppm active quaternary solution by adding 1 ounce of sanitizer to 4 gallons of water ...Prepare a fresh solution daily or more frequently as soil is apparent ....” Document titled, “QT-10 Hydrion Sanitizer test kits” revealed: “ ...Description. Provides a simple, reliable, and economical means to measure quaternary concentration of ammonium, chlorine, and iodine sanitizer solutions Federal, State, and Local health regulations require users of Quaternary Ammonium Sanitizer Solutions to have appropriate test kits available to verify the strength of sanitizer solutions. Sanitizer solutions are essential in the food service industry to ensure that sanitizers are at the proper concentration specified by the individual manufacturer ....” Hospital document titled, “Diversey J-512 Sanitizer” Daily testing log. Log requested, none provided. A request was made for Quat test strips manufacturer ’ s instructions, none provided. Observation on tour of the kitchen on 08/06/2024, Employee # 34 was requested to demonstrate to the surveyors the process when testing the sanitizer in the sinks and sanitizing buckets. . Employee # 34 demonstrated how the staff tested the concentration by dipping the Quat test strip into the solution and then comparing it to the guide on the test strips. During the demonstration, the test strips did not change color. The test was repeated twice with no change in results. Employee # 34 confirmed during an interview conducted on 08/06/2024, that there should be change in the color of the Quat test strip indicating if the sanitizer was within acceptable range for sanitizing the counters, equipment and dishes. Employee #34 confirmed that there was no documentation that the concentration of the sanitizer was being tested on a daily basis. Employee 34 confirmed during an interview conducted on 08/06/2024, that the kitchen staff had been diluting the concentration. Employee # 34 stated the staff have now been re-educated and tested on the process for mixing and testing the Diversey J-512. Sanitizer. Employee # 30 confirmed in an interview dated 08/09/2024, that the instructions for diluting and testing the Diversey J-512 Sanitizer have now been placed in the employee training binder. “ ...Topic: Proper Manual dilution of Diversey J-512 Quat Sanitizer in the 3-Compartment sink. Step 1. Fill the Sanitizer Compartment with 4 Gallons of water at 75 degrees. Step 2. Add 1. oz of Diversey J-512 Quat Sanitizer to the compartment filled with water. Step 3. Stir water and Diversey J-512 sanitizer solution to ensure proper dilution. Step 4. Use Diversey QT-10 test strips to ensure the solution is within 200-400 PPM ....” A policy regarding kitchen cleaning was requested, the facility was unable to provide. The facility provided a document titled, “Kitchen Schedule”, which contained specific cleaning assignments for each shift. The facility was unable to provide completed kitchen cleaning logs for the past year. A request was made for documentation regarding vent hood maintenance, none was provided. Document titled, “Identified Maintenance Issues” was proved by the facility which revealed the following information on the document: Date; Equipment; Issue; Completed Yes/No. Review of the kitchen “Identified Maintenance Issues” log for the past year revealed a list of the following requested kitchen repairs for the last year: 4/28/2023 Garbage Disposal/ Broken /Repaired: Yes 06/05/2023 3 Comp sink/ Leak/ Repaired: Yes 06/13/2023 Cold prep sink/ Won ’ t shut off/Repaired: no documentation 06/13/2023 Produce Cooler/ Door broke, quote obtained/Repaired: no documentation 06/13/202 Lighting in walk in cooler/Dull, burning out/Repaired: no documentation 06/13/2023 Plastic guards on walls/Broken, sharp plastic sticking out/Repaired: no documentation 06/13/2023 Cafe Door/Off hinges/Repaired: no documentation 06/20//2023 Cambro Hot Box/Not heating up/Repaired: no documentation 06/20/2023 Steamer/Handle broken/Repaired: no documentation 06/20/2023 Mixer/Front Plate Missing/Repaired: no documentation 06/20/202 Equipment on wheels/Equipment need to be attached to the wall/Repaired: no documentation 06/20/2023 Blast Chiller/Doesn ’ t work/Repaired: no documentation 06/20/2023 Small hot box/Needs a knob/Repaired: no documentation 06/20/2023 Oven/Missing panel/Repaired: no documentation 06/22/2023 Front Door/magnets broken/Repaired: no documentation 07/01/2023 Tilt Skillet/not working/Repaired: no documentation 07/06/2023 Garbage disposal/motor not kicking in/Repaired: yes reset button pushed 07/12/2023 Air Conditioner/ not working/Repaired: yes 07/14/2023 Flat top/Not working/Repaired: no documentation 07/19/2023 Running water dishroom/water not shutting off/ Repaired: yes 08/03/2023 Plate Cover/wires are exposed/Repaired: yes 08/31/2023 Freezer/out of range/Repaired: no documentation 09/12/2023 Freezer/Cover off fan, broken, no longer connected/Repaired: no documentation 09/29/2023 Water/ Water in dept not working/Repaired: yes 10/17/2023 Alarm/Alarm continues to go off/Repaired: no documentation 10/28/2023 Lavatory/All women’s toilets are clogged up/Repaired: no documentation 10/18/2023 Water/Cannot turn off/Repaired: yes 11/03/2023 Lavatory/All the womens toilets are clogged up/ Repaired: no documentation 11/09/2023 Flat top Grill/ not working/Repaired: no documentation 11/28/2023 Cooler/Light bulb out/Repaired: no documentation 12/01/2023 Carts/broken racks/Repaired: no documentation 12/12/2023 Ice Machine/Broken Door/Repaired: no documentation 12/12/2023 Faucet/ Faucet broken in middle sink/Repaired: no documentation 12/14/2023 Air/Very Cold in Dept/Repaired: no documentation 12/14/2023 Sewage/Sewage coming up through the drain/ Repaired: no documentation 12/16/2023 Coffee Machine/Water continues to run/Repaired: no documentation 12/28/2023 Sprayer/leaking in dishroom/Repaired: no documentation 12/28/2023 Pipes/Leaking under sinks/Repaired: no documentation 01/09/2024 Cold/Cold in department/Repaired: no documentation 01/11/2024 Lights/lights out in hallway/Repaired: no documentation 01/17/2024 Mens Toilet/toilet overflowing/Repaired: no documentation 01/26/2024 Sewage/Sewage coming through drain/Repaired: no documentation 02/22/2024 Sewage/sewage coming through drain/Repaired: no documentation 02/27/2024 Sink in back/keeps getting clogged/Repaired: no documentation 02/29/2024 Sewer drains/Sewage coming through drains again/Repaired: no documentation 03/06/2024 Sewage/Coming through drains again/ Repaired: no documentation 03/23/2024 Sewage/Coming through drains again/ Repaired: no documentation 04/24/2024 Sanitizing unit/clogged up/Repaired: no documentation 06/06/2024 Drains/Sewer coming up/Repaired: no documentation 06/11/2024 Drains/Sewer coming up/Repaired: no documentation 06/28/2024 Drains/Sewer coming up through drain/Repaired: no documentation 07/05/2024 Refrigerator/ Temperature/ Repaired: no documentation 07/09/2024 Cooler/The door can ’ t stay closed/Repaired: no documentation 07/09/2024 Drains/Sewer coming up/Repaired: no documentation 07/19/2024 Bathroom sinks/Mens bathroom sink is clogged/Repaired: no documentation 08/01/2024 Sewer/Sewer coming up/Repaired: no documentation 08/05/2024 Mens Bathroom/Mens toilet sink is clogged/Repaired: no documentation Employee #4 confirmed on 08/06/2024 that the maintenance log was incomplete and there was no documentation if repairs had been completed. Observation while on tour of the facility kitchen revealed three stove/oven units that were non-functioning that were encrusted with a hardened, greasy, blackened material with dried food residue and debris covering each stove top. Further observation revealed one functioning stove/oven that had dried, blackened material on the steel backsplash of the stovetop, also a blackened, greasy appearing material was noted on the burners and surrounding areas of the stovetop. Also observed on the vent hoods were dust and dirt particles with a greasy appearing substance covering the interior of the vent hood. Further observation revealed the floor of the kitchen was dirty with a dried black colored substance along the edges of the stove/ovens and refrigerators. Staff were improperly diluting the dish cleaning concentration when washing dishes, pots and pans. Also observed in the kitchen was a sink encrusted with black debris that had an empty water bottle and used gloves present in the sink. Uncovered floor drains with no protective screens present were noted in the floor of the kitchen area. Paper products were noted stored on a metal storage rack that was adjacent to and abutting the stove/oven next to an open flame on the stove. Further observation revealed a white powdery substance on the side of the walls and floor of one of the walk in coolers. Further observation revealed portable fans and portable coolers were in operation and blowing air into the food preparation as there was no functioning central air conditioning in the area. Food products were found to be stored in their original corrugated cardboard boxes in the walk in coolers, freezers and on the food prep counters. Expired food items were observed on counters and in the walk in coolers. Inspection of the floors under the stove/ovens revealed the floor was encrusted with a gray/black dusty like material, dried macaroni products,dried food residue and small black pellets that resembled rodent droppings. Employee #4 confirmed the non-functioning equipment needed to be removed from the kitchen area. Employee #4 confirmed there were no documented kitchen cleaning logs available. Employee #4 confirmed there was no functioning centralized air conditioning in the kitchen area. Employee #4 confirmed the kitchen equipment appeared to be unclean. 3 4, &5. The United States Food and Drug Administration publication, Food Code: 2017 Recommendations of the United States Public Health Service, Food and Drug Administration incorporated by reference in subsection (A) from R9-8-101 Food Establishments Purpose and Definition and R9-10-231 Dietary Services requires: “...Preventing Contamination from the Premises...3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor...6-5 MAINTENANCE AND OPERATION Subpart 6-501 Premises, Structures, Attachments, and Fixtures...PHYSICAL FACILITIES shall be maintained in good repair. 6-501.12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean....” The United States Food and Drug Administration publication, Food Code: 2017 Recommendations of the United States Public Health Service, Food and Drug Administration incorporated by reference in subsection (A) from R9-8-101 Food Establishments Purpose and Definition and R9-10-231 Dietary Services requires: “...3-305.14...Food Preparation. During preparation, unPACKAGED FOOD shall be protected from environmental sources of contamination...Preventing Contamination from Other Sources 3-307.11 Miscellaneous Sources of Contamination. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.....” Hospital policy titled, “Food Production, Service, Storage, and Distribution Standards”, revealed: “ ...Temperatures of food storage areas and cold food vendors are monitored and action is taken to maintain temperatures within ranges recommended by licensing and surveying agencies ...Each mechanically refrigerated unit storing potentially hazardous food shall be provided with a numerically scaled indicating thermometer, accurate to +/-2 degrees F. ...Food stored frozen should be kept no longer than 90 days ...Food stored refrigerated should be kept no longer than the expiration date ...Most products contain an expiration date. The words “sell by” or “use by” should precede the date ...The use by date is the last date that a food can be consumed; do not sell [products in retail areas or place on patient trays past the date on the product. Do not use products in recipes past the use by date ....” Hospital policy titled ’ “Food and Supply Storage”, revealed: “ ...All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption ...Date and rotate items, first in, first out. Discard food past the use by or expiration date ....” Hospital document titled, “St. Luke ’ s Behavioral Health Hospital 2024 Infection Control Program, Goals, Objectives & Risk Assessment”, revealed: “ ...Goals 12. Ensure food-safety for our patients and staff in order to reduce the risk of transmission of infectious disease via foodborne pathogens ...Food should be received and stored under conditions that maintain nutritional value and minimize the risk of contamination by microorganisms, insects, rodents, and toxic substances ...Records of food and equipment temperatures must be maintained, and remediation steps developed wen systems are not in control ...Corrugated cardboard used to deliver products, should be removed as soon as possible because these boxes may deteriorate or damage the product, the product may leak, or water damage may be present; any moisture rots the boxes, and these conditions allow for pest infestation and possible damage to the product ...Any food left in the refrigerator without a discard date is discarded by the Food Nutrition employee ....” Temperature Logs were requested for the walk-in coolers and freezers for the past year. The facility provided temperature logs dated January 2023 through April 2023, for 3 unidentified freezers and 12 unidentified refrigerators. Temperature logs were provided the months of October 2023 through December 2023, and August 2024 with freezers identified as: Grill Freezer, Freezer 1 and Freezer 2; and Refrigerators were identified as: Walk-in 1, Walk-in 2, Produce, Cook Fridge, Cook Prep, Small Fridge, Milk, Trayline 1, Trayline2 and one unidentified. The facility was unable to provide temperature logs for the other months as requested.. Review of the temperature logs revealed required freezer temperature range -10 degrees F minimum and 0 degrees F maximum. Review of the refrigerator temperature logs revealed required milk refrigerator temperature range 36 degrees F Minimum and 40 degrees F maximum, and required walk-in coolers temperature range 34 degrees F and 40 degrees F maximum. Review of the freezer and refrigerator logs revealed the following: Month of January 2023: Review of the three (3) freezer temperature logs revealed no identifiers on the freezer logs to identify which freezer the temperatures were taken. Further review of the freezer temperature logs revealed temperatures were taken 186 times for the three (3) freezers with a total of 23 temperatures over the required maximum 0 degrees F and no corrective action was documented. Review of the twelve (12) walk-in coolers/refrigerator logs revealed no identifiers on the refrigerator logs to identify which refrigerator the temperatures were taken, Further review of the refrigerator temperature logs revealed temperatures were taken 744 times for the twelve (12) refrigerators with a total of 371 temperatures under the required minimum 34 degrees F and 20 temperatures over the required 40 degrees F with no corrective action was documented. Month of February 2023: Review of the three (3) freezers temperature logs revealed temperatures were logged 168 times. Review of the logged temperatures revealed four (4) temperatures over the required maximum 0 degrees F and no corrective action was documented. Review of the twelve (12) walk-in coolers/refrigerator logs revealed 612 temperatures logged. Review of the logged temperatures revealed 224 temperatures under the required minimum 34 degrees F and 26 temperatures over the required 40 degrees F with no corrective action documented. Month of March 2023: Review of the three (3) freezers temperature logs revealed temperatures were logged 186 times. Review of the logged temperatures revealed 42 temperatures over the required maximum 0 degrees F and no corrective action was documented. Review of the twelve (12) walk-in coolers/refrigerator logs revealed 744 temperatures logged. Review of the logged temperatures revealed 270 temperatures under the required minimum 34 degrees F and 44 temperatures over the required 40 degrees F with no corrective action documented. Month of April 2023: Review of the three (3) freezers temperature logs revealed temperatures were logged 180 times. Review of the logged temperatures revealed 15 temperatures over the required maximum 0 degrees F and no corrective action was documented. Review of the twelve (12) walk-in coolers/refrigerator logs revealed 720 temperatures logged. Review of the logged temperatures revealed 154 temperatures under the required minimum 34 degrees F and 28 temperatures over the required 40 degrees F with no corrective action documented. Months of May, June, July, August, and September 2023 not provided. Month of October 2023: Review of the three (3) freezers temperature logs revealed temperatures were logged 186 times. Review of the logged temperatures revealed 186 temperatures over the required maximum 0 degrees F and no corrective action was documented. Review of the twelve (12) walk-in coolers/refrigerator logs revealed 744 temperatures logged. Review of the logged temperatures revealed 234 temperatures under the required minimum 34 degrees F and 10 temperatures over the required 40 degrees F with no corrective action documented. Month of November 2023: Review of the three (3) freezers temperature logs revealed temperatures were logged 180 times. Review of the logged temperatures revealed 180 temperatures over the required maximum 0 degrees F and no corrective action was documented. Review of the twelve (12) walk-in coolers/refrigerator logs revealed 720 temperatures logged. Review of the logged temperatures revealed 193 temperatures under the required minimum 34 degrees F with no corrective action documented. Month of December 2023: Review of the three (3) freezers temperature logs revealed temperatures were logged 186 times. Review of the logged temperatures revealed 184 temperatures over the required maximum 0 degrees F and no corrective action was documented. Review of the twelve (12) walk-in coolers/refrigerator logs revealed 744 temperatures logged. Review of the logged temperatures revealed 205 temperatures under the required minimum 34 degrees F and 1 temperature over the required 40 degrees F with no corrective action documented. Month of August 01-07, 2024: Review of two (2) freezer temperature logs revealed 28 temperatures logged. Review of the logged temperatures revealed 5 temperatures over the required maximum 0 degrees F and no corrective action was documented. Review of five (5) walk-in cooler/refrigerator temperature logs revealed 70 temperatures logged. Review of the logged temperatures revealed 23 temperatures under the required minimum 34 degrees F and 4 temperatures over the required 40 degrees F with no corrective action documented. Also noted the temperature log of the Produce Refrigerator was a notation on 08/08/2024 “Cooler shot, Down”. Employee #30 confirmed that the temperature logs provided dated January 2023 to April 2023, October 2023 to December 2023, and August 2024. were the only temperature logs that were available, no other dates could be located by the facility. Observation while on tour of the kitchen on 08/06/2024 revealed one non-functioning refrigerator with yellow caution tape across the door. Further observation revealed two (2) freezers of three (3) in use and five (5) of twelve (12) walk-in coolers/ refrigerators in use. Observation while on tour of the kitchen on 08/07/2024 revealed on the counter by the refrigerator a gallon container of milk with visible clumping of milk product in the container with an expiration date of 06/15/2024. Also observed while on tour in a walk-in cooler were 6 containers of blueberries with mold present on the fruit with expiration date of 07/30/2024. Observation while on tour of the kitchen on 08/06/2024 and 08/07/2024 revealed food items in corrugated cardboard boxes on the counter in the food prep area. Observation also revealed multiple food items in their original corrugated cardboard boxes in the freezers and walk-in coolers. A white powdery substance was noted on the sides of the walls and floor of one of the walk-in coolers. Employee #34 confirmed on 08/07/2024 that food items were expired and that food was being stored in corrugated cardboard boxes. 6. The United States Food and Drug Administration publication, Food Code: 2017 Recommendations of the United States Public Health Service, Food and Drug Administration incorporated by reference in subsection (A) from R9-8-101 Food Establishments Purpose and Definition and R9-10-231 Dietary Services requires: ..3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under ¶ (B) and in ¶ (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57oC (135oF) or above, except that roasts cooked to a temperature and for a time specified in ¶ 3-401.11(B) or reheated as specified in ¶ 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; P or (2) At 5oC (41oF) or less. P (B) EGGS that have not been treated to destroy all viable Salmonellae shall be stored in refrigerated EQUIPMENT that maintains an ambient air temperature of 7°C (45°F) or less. P (C) TIME/TEMPERATURE CONTROL FOR SAFETY FOOD in a homogenous liquid form may be maintained outside of the temperature control requirements, as specified under ¶ (A) of this section, while contained within specially designed EQUIPMENT that complies with the design and construction requirements as specified under ¶ 4¿04.13(E)....Time - maximum up to 6 hours (C) If time without temperature control is used as the public health control up to a maximum of 6 hours: (1) The FOOD shall have an initial temperature of 5oC (41oF) or less when removed from temperature control and the FOOD temperature may not exceed 21oC (70oF) within a maximum time period of 6 hours; (2) The FOOD shall be monitored to ensure the warmest portion of the FOOD does not exceed 21oC (70oF) during the 6-hour period, unless an ambient air temperature is maintained that ensures the FOOD does not exceed 21oC (70oF) during the 6¿ hour holding period; (3) The FOOD shall be marked or otherwise identified to indicate: (a) The time when the FOOD is removed from 5oC (41oF) or less cold holding temperature control, Pf and (b) The time that is 6 hours past the point in time when the FOOD is removed from cold holding temperature control; Pf (4) The FOOD shall be: (a) Discarded if the temperature of the FOOD exceeds 21°C (70°F), P or (b) Cooked and served, served at any temperature if READY- TO-EAT, or discarded within a maximum of 6 hours from the point in time when the FOOD is removed from 5oC (41oF) or less cold holding temperature control; P and (5) The FOOD in unmarked containers or PACKAGES, or marked with a time that exceeds the 6-hour limit shall be discarded....” Policy titled, “Food Handling Guidelines”, revealed: “...Temperatures of food shall be monitored using accurate thermometers...Holding Temperatures: Hot Holding: Foods should be held hot for service at a temperature of 140o degrees F or higher...Monitor temperatures of food held in a hot holding box by checking at least one pan of food every two hours (Hot Holding Box Form)...Temperatures of hot food in service will be documented...Patient service during traditional meal periods: at the beginning of service and either middle or end of patient service on the Taste Temperature Record...Cold Holding: Foods should be held cold for service at a temperature of 40o degrees F or less....” A review of the Patient Line Food Temperature logs for the last three months was requested. No temperature logs for patient food were provided. Employee #30 confirmed on 08/12/2024 that there were no temperature logs for patient food available.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 48110 Based on review of documents, American National Standards Institute “”Standard 170-2017, Ventilation of Health Care Guidelines”, Arizona Administrative Code, United States Food and Drug Administration publication, Food Code: 2017 Recommendations of the United States Public Health Service, Phoenix Fire Department Fire Code, observations and interviews, it was determined the Hospital failed to ensure the hospital was adequately maintained by: 1. failing to ensure kitchen equipment was maintained and operational. 2. failing to ensure HVAC System was maintained and operational. 3. failing to ensure fire alarms were maintained and operational. 4. failing to ensure plumbing leaks and drainage pipes were maintained and operational. Findings include: Hospital policy titled, “Equipment Maintenance, Inspection, and Repair”, revealed: “ ...Proper maintenance of the physical plant and all equipment is the FNS Department is the responsibility of the DFNS in cooperation with the Maintenance Department and subject to policies and procedures set forth by the facility ’ s administration ...The DFNS is directed or had knowledge of all routine, periodic, and critical maintenance work done to the physical plant or equipment in the department ...To ensure that all equipment is in safe operating condition, an equipment inspection program is followed ...FNS requests equipment repairs in writing from the Maintenance Department according to established procedures ...Repair to essential equipment are initiated by the Maintenance Department within the agreed upon timeframe ...A preventative maintenance plan should cover: regular inspection/maintenance by the maintenance department; periodic servicing by service companies contracted through the Maintenance Department ...Complete the Equipment Inspection Checklist monthly ...Perform the following checks of each item and any or all supporting parts or connections: visual inspection to determine that the unit is in good condition, is not being used beyond its safe operating limits, and is effectively fulfilling its intended use ...Identify repairs needed ...Monitor completion of repairs ....” 1. The United States Food and Drug Administration publication, Food Code: 2017 Recommendations of the United States Public Health Service, Food and Drug Administration incorporated by reference in subsection (A) from R9-8-101 Food Establishments Purpose and Definition and R9-10-231 Dietary Services requires: “...4-6 CLEANING OF EQUIPMENT AND UTENSILS...4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch....(B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris....” The United States Food and Drug Administration publication, Food Code: 2017 Recommendations of the United States Public Health Service, Food and Drug Administration incorporated by reference in subsection (A) from R9-8-101 Food Establishments Purpose and Definition and R9-10-231 Dietary Services requires: “...6-5 MAINTENANCE AND OPERATION Subpart 6-501 Premises...PHYSICAL FACILITIES shall be maintained in good repair. 6-501.12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. 4-6 CLEANING OF EQUIPMENT AND UTENSILS...4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch....(B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris....” Hospital policy titled, “Equipment Maintenance, Inspection, and Repair”, revealed: “ ...Proper maintenance of the physical plant and all equipment is the FNS Department is the responsibility of the DFNS in cooperation with the Maintenance Department and subject to policies and procedures set forth by the facility ’ s administration ...The DFNS is directed or had knowledge of all routine, periodic, and critical maintenance work done to the physical plant or equipment in the department ...To ensure that all equipment is in safe operating condition, an equipment inspection program is followed ...FNS requests equipment repairs in writing from the Maintenance Department according to established procedures ...Repair to essential equipment are initiated by the Maintenance Department within the agreed upon timeframe ...A preventative maintenance plan should cover: regular inspection/maintenance by the maintenance department; periodic servicing by service companies contracted through the Maintenance Department ...Complete the Equipment Inspection Checklist monthly ...Perform the following checks of each item and any or all supporting parts or connections: visual inspection to determine that the unit is in good condition, is not being used beyond its safe operating limits, and is effectively fulfilling its intended use ...Identify repairs needed ...Monitor completion of repairs ....” Hospital policy titled, “Food and Supply Storage”, revealed: “ ...Mold Prevention: Fix leaky plumbing and leaks in the building envelope as soon as possible; Keep heating, ventilation and air conditioning (HVAC) drip pans clean, flowing properly, and unobstructed ...Clean and dry wet or damp spots within 48 hours ....” A policy regarding kitchen cleaning was requested, the facility was unable to provide. The facility provided a document titled, “Kitchen Schedule”, which contained specific cleaning assignments for each shift. The facility was unable to provide completed kitchen cleaning logs for the past year. A request was made for documentation regarding vent hood maintenance, none was provided. Document titled, “Identified Maintenance Issues” was proved by the facility which revealed the following information on the document: Date; Equipment; Issue; Completed Yes/No. Review of the kitchen “Identified Maintenance Issues” log for the past year revealed a list of the following requested kitchen repairs for the last year: 4/28/2023 Garbage Disposal/ Broken /Repaired: Yes 06/05/2023 3 Comp sink/ Leak/ Repaired: Yes 06/13/2023 Cold prep sink/ Won ’ t shut off/Repaired: no documentation 06/13/2023 Produce Cooler/ Door broke, quote obtained/Repaired: no documentation 06/13/202 Lighting in walk in cooler/Dull, burning out/Repaired: no documentation 06/13/2023 Plastic guards on walls/Broken, sharp plastic sticking out/Repaired: no documentation 06/13/2023 Cafe Door/Off hinges/Repaired: no documentation 06/20//2023 Cambro Hot Box/Not heating up/Repaired: no documentation 06/20/2023 Steamer/Handle broken/Repaired: no documentation 06/20/2023 Mixer/Front Plate Missing/Repaired: no documentation 06/20/202 Equipment on wheels/Equipment need to be attached to the wall/Repaired: no documentation 06/20/2023 Blast Chiller/Doesn ’ t work/Repaired: no documentation 06/20/2023 Small hot box/Needs a knob/Repaired: no documentation 06/20/2023 Oven/Missing panel/Repaired: no documentation 06/22/2023 Front Door/magnets broken/Repaired: no documentation 07/01/2023 Tilt Skillet/not working/Repaired: no documentation 07/06/2023 Garbage disposal/motor not kicking in/Repaired: yes reset button pushed 07/12/2023 Air Conditioner/ not working/Repaired: yes 07/14/2023 Flat top/Not working/Repaired: no documentation 07/19/2023 Running water dishroom/water not shutting off/ Repaired: yes 08/03/2023 Plate Cover/wires are exposed/Repaired: yes 08/31/2023 Freezer/out of range/Repaired: no documentation 09/12/2023 Freezer/Cover off fan, broken, no longer connected/Repaired: no documentation 09/29/2023 Water/ Water in dept not working/Repaired: yes 10/17/2023 Alarm/Alarm continues to go off/Repaired: no documentation 10/28/2023 Lavatory/All women’s toilets are clogged up/Repaired: no documentation 10/18/2023 Water/Cannot turn off/Repaired: yes 11/03/2023 Lavatory/All the womens toilets are clogged up/ Repaired: no documentation 11/09/2023 Flat top Grill/ not working/Repaired: no documentation 11/28/2023 Cooler/Light bulb out/Repaired: no documentation 12/01/2023 Carts/broken racks/Repaired: no documentation 12/12/2023 Ice Machine/Broken Door/Repaired: no documentation 12/12/2023 Faucet/ Faucet broken in middle sink/Repaired: no documentation 12/14/2023 Air/Very Cold in Dept/Repaired: no documentation 12/14/2023 Sewage/Sewage coming up through the drain/ Repaired: no documentation 12/16/2023 Coffee Machine/Water continues to run/Repaired: no documentation 12/28/2023 Sprayer/leaking in dishroom/Repaired: no documentation 12/28/2023 Pipes/Leaking under sinks/Repaired: no documentation 01/09/2024 Cold/Cold in department/Repaired: no documentation 01/11/2024 Lights/lights out in hallway/Repaired: no documentation 01/17/2024 Mens Toilet/toilet overflowing/Repaired: no documentation 01/26/2024 Sewage/Sewage coming through drain/Repaired: no documentation 02/22/2024 Sewage/sewage coming through drain/Repaired: no documentation 02/27/2024 Sink in back/keeps getting clogged/Repaired: no documentation 02/29/2024 Sewer drains/Sewage coming through drains again/Repaired: no documentation 03/06/2024 Sewage/Coming through drains again/ Repaired: no documentation 03/23/2024 Sewage/Coming through drains again/ Repaired: no documentation 04/24/2024 Sanitizing unit/clogged up/Repaired: no documentation 06/06/2024 Drains/Sewer coming up/Repaired: no documentation 06/11/2024 Drains/Sewer coming up/Repaired: no documentation 06/28/2024 Drains/Sewer coming up through drain/Repaired: no documentation 07/05/2024 Refrigerator/ Temperature/ Repaired: no documentation 07/09/2024 Cooler/The door can ’ t stay closed/Repaired: no documentation 07/09/2024 Drains/Sewer coming up/Repaired: no documentation 07/19/2024 Bathroom sinks/Mens bathroom sink is clogged/Repaired: no documentation 08/01/2024 Sewer/Sewer coming up/Repaired: no documentation 08/05/2024 Mens Bathroom/Mens toilet sink is clogged/Repaired: no documentation Employee #4 confirmed on 08/06/2024 that the maintenance log was incomplete and there was no documentation if repairs had been completed. Observation while on tour of the facility kitchen revealed three stove/oven units that were non-functioning that were encrusted with a hardened, greasy, blackened material with dried food residue and debris covering each stove top. Further observation revealed one functioning stove/oven that had dried, blackened material on the steel backsplash of the stovetop, also a blackened, greasy appearing material was noted on the burners and surrounding areas of the stovetop. Also observed on the vent hoods were dust and dirt particles with a greasy appearing substance covering the interior of the vent hood. Further observation revealed the floor of the kitchen was dirty with a dried black colored substance along the edges of the stove/ovens and refrigerators. Staff were improperly diluting the dish cleaning concentration when washing dishes, pots and pans. Also observed in the kitchen was a sink encrusted with black debris that had an empty water bottle and used gloves present in the sink. Uncovered floor drains with no protective screens present were noted in the floor of the kitchen area. Paper products were noted stored on a metal storage rack that was adjacent to and abutting the stove/oven next to an open flame on the stove. Further observation revealed a white powdery substance on the side of the walls and floor of one of the walk in coolers. Further observation revealed portable fans and portable coolers were in operation and blowing air into the food preparation as there was no functioning central air conditioning in the area. Food products were found to be stored in their original corrugated cardboard boxes in the walk in coolers, freezers and on the food prep counters. Expired food items were observed on counters and in the walk in coolers. Inspection of the floors under the stove/ovens revealed the floor was encrusted with a gray/black dusty like material, dried macaroni products,dried food residue and small black pellets that resembled rodent droppings. Employee #4 confirmed the non-functioning equipment needed to be removed from the kitchen area. Employee #4 confirmed there were no documented kitchen cleaning logs available. Employee #4 confirmed there was no functioning centralized air conditioning in the kitchen area. Employee #4 confirmed the kitchen equipment appeared to be unclean. 2. The American National Standards Institute “Standard 170-2017, Ventilation of Health Care Guidelines” reveals that patient rooms, patient seclusion rooms and patient common areas should be maintained between 70 and 75 degrees fahrenheit. Hospital document titled, “Utilities Management Plan 2024”, revealed: “ ...The utility systems addressed by this plan include: ...Heating, ventilating, air conditioning (HVAC), and refrigeration ...The hospital adopts and complies with the NFPA Life Safety Code 101, 2012 Edition and the NFPA 99, 2012 Edition, and complies with current CMS requirements ... Utility Systems Maintenance: To maintain fully functioning utilities, maintenance, inspection activities and frequencies are documented and controlled in the BHC maintenance work order system. The BHC will achieve a 100% completion rate for all high-risk and infection control utility system components ...The manufacturers maintenance procedures are available in the facilities office and documented on work orders. At a minimum, the hospital utilizes manufacturers recommended standards, or the ASHE maintenance management for Health Care Facilities plans where manufacturers guidelines are not available ...Environmental Monitoring ...Appropriate maintenance of the heating, ventilation, and air conditioning systems is critical to the control of airborne contaminants. Maintenance of the appropriate pressure relationships, air exchange rates, filtration efficiencies, temperature and humidity are part of this process ....” Work orders for the HVAC system for the last 12 months were requested. Review of the work orders presented revealed 37 work orders were submitted. Review of Hospital documents titled, “Work Orders”, revealed eight work orders for the cooling system generated on 09/29/2023, 01/10/2024, 03/20/2024, 04/08/2024, 04/24/2024, 06/03/2024, 07/07/2024, and 08/06/2024 were not marked completed. The Department received notification on 08/09/2024 from Employee #41 that the cooling system at the Hospital was not functional beginning 08/08/2024 evening. Employee #3 confirmed during an interview conducted on 08/12/2024 that the Hospital has three chillers on the building for the cooling system. Employee #3 confirmed one chiller was already not functional, and the remaining two chillers stopped operating on 08/08/2024 evening. Employee #4 confirmed on 08/12/2024 the first chiller stopped operating in November 2023 and repairs had not been made. 3. A request was made for the hospital’s current fire inspection. None was provided. A request was made to the Phoenix Fire Department for the hospital’s current fire inspection. A fire inspection report dated 10/06/2023 was provided by the Phoenix Fire Department. Document titled, “City of Phoenix Fire Prevention Notice of Non-Compliance”, dated 10/06/2023 revealed: “...All Fire Code References are Phoenix City Code §15. Code Title #1: PFC901.6 Inspection, testing and maintenance. Code Text #1: Fire detection and alarm systems, emergency alarm systems, gas detection systems, fire-extinguishing systems, smoke control systems, mechanical smoke exhaust systems, and smoke and heat vents shall be maintained in an operative condition at all times, and shall be replaced or repaired where defective. Nonrequired fire protection systems shall be inspected and tested by a contractor licensed by the State of Arizona who is a current qualified contractor by the Phoenix Fire Department to work on the particular fire protection system being inspected or tested in accordance with NFPA standards, see Section 108.1. It shall be the responsibility of the owner to ensure that these requirements are met. Non-Compliant Condition #1: The fire pump has a reported deficiency on the most recent fire servicing report. Correction Required #1: The fire pump system shall be inspected and maintained in accordance with the Phoenix Fire Code...Obtain system signoffs (Green tags) for each system repaired or corrected. Required Compliance Date #1: 10/06/2023. Violation Corrected #1 In compliance on #1: NO Code Title #2: PFC901.6 Inspection, testing and maintenance. Code Text #2: Fire detection and alarm systems, emergency alarm systems, gas detection systems, fire-extinguishing systems, smoke control systems, mechanical smoke exhaust systems, and smoke and heat vents shall be maintained in an operative condition at all times, and shall be replaced or repaired where defective. Nonrequired fire protection systems shall be inspected and tested by a contractor licensed by the State of Arizona who is a current qualified contractor by the Phoenix Fire Department to work on the particular fire protection system being inspected or tested in accordance with NFPA standards, see Section 108.1. It shall be the responsibility of the owner to ensure that these requirements are met. Non-Compliant Condition #2: The fire alarm system has reported deficiencies on the most recent fire servicing report. Correction Required #2: The fire alarm system shall be inspected and maintained in accordance with the Phoenix Fire Code...Obtain system signoffs (Green tags) for each system repaired or corrected. Required Compliance Date #2: 10/06/2023. Violation Corrected #2 In Compliance on #2: NO Code Title #3: PFC901.6 Inspection, testing and maintenance. Code Text #3: Fire detection and alarm systems, emergency alarm systems, gas detection systems, fire-extinguishing systems, smoke control systems, mechanical smoke exhaust systems, and smoke and heat vents shall be maintained in an operative condition at all times, and shall be replaced or repaired where defective. Nonrequired fire protection systems shall be inspected and tested by a contractor licensed by the State of Arizona who is a current qualified contractor by the Phoenix Fire Department to work on the particular fire protection system being inspected or tested in accordance with NFPA standards, see Section 108.1. It shall be the responsibility of the owner to ensure that these requirements are met. Non-Compliant Condition #3: The kitchen hood system is past due for its annual inspection, testing, and maintenance. Correction Required #3: The kitchen hood system shall be inspected and maintained in accordance with the Phoenix Fire Code...Obtain system signoffs (Green tags) for each system repaired or corrected. Required Compliance Date #3: 10/06/2023. Violation Corrected #3 In Compliance on #2: NO....” Review of document titled, “City of Phoenix Fire Department Fire Prevention”, revealed: “...As noted in the Notice of Non-Compliance (N.O.N.C.) issued on October 6, 2023, several violations were identified that require immediate attention...Although the patients have been evacuated due to the inoperability of your chillers, your staff remains on-site. To ensure their safety and permit continued staff occupancy, the following actions must be implemented immediately: 1. Unlock All Egress Doors: All egress doors must be unlocked to ensure free and unobstructed exot for all personnel working in the building. 2. Implement A Fire Watch: A two-person fire watch is required,one for each building. In the absence of a functional fire alarm system, fire watch personnel must be designated to monitor fires and notify others in the event of an emergency. These individuals shoudl be able to communicate effectively with each other and contact emergency services (911) if necessary. Due to these outstanding fire protection issues, your operational permit has been temporarily revoked. In order to reinstate the permit and allow for occupancy of patients in the future, please address the following: 1. Restore Fire Alarm System: The fire alarm system in the Behavioral Health Center (BHC) must be fully operational. 2. Submit Evacuation Procedures: Provide detailed evacuation procedures to the fire department for review and consideration....” Employee #4 confirmed that a copy of a current fire inspection was not available. 4. Hospital policy titled, “Food and Supply Storage”, revealed: “ ...Mold Prevention: Fix leaky plumbing and leaks in the building envelope as soon as possible; Keep heating, ventilation and air conditioning (HVAC) drip pans clean, flowing properly, and unobstructed ...Clean and dry wet or damp spots within 48 hours ....” Document titled, “Identified Maintenance Issues” was proved by the facility which revealed the following information on the document: Date; Equipment; Issue; Completed Yes/No. Review of the kitchen “Identified Maintenance Issues” log for the past year revealed the following requested kitchen plumbing repairs for the last year: 06/13/2023 Cold prep sink/ Won ’ t shut off/Repaired: no documentation 10/28/2023 Lavatory/All women’s toilets are clogged up/Repaired: no documentation 11/03/2023 Lavatory/All the womens toilets are clogged up/ Repaired: no documentation 12/12/2023 Faucet/ Faucet broken in middle sink/Repaired: no documentation 12/14/2023 Sewage/Sewage coming up through the drain/ Repaired: no documentation 12/28/2023 Sprayer/leaking in dishroom/Repaired: no documentation 12/28/2023 Pipes/Leaking under sinks/Repaired: no documentation 01/17/2024 Mens Toilet/toilet overflowing/Repaired: no documentation 01/26/2024 Sewage/Sewage coming through drain/Repaired: no documentation 02/22/2024 Sewage/sewage coming through drain/Repaired: no documentation 02/27/2024 Sink in back/keeps getting clogged/Repaired: no documentation 02/29/2024 Sewer drains/Sewage coming through drains again/Repaired: no documentation 03/06/2024 Sewage/Coming through drains again/ Repaired: no documentation 03/23/2024 Sewage/Coming through drains again/ Repaired: no documentation 04/24/2024 Sanitizing unit/clogged up/Repaired: no documentation 06/06/2024 Drains/Sewer coming up/Repaired: no documentation 06/11/2024 Drains/Sewer coming up/Repaired: no documentation 06/28/2024 Drains/Sewer coming up through drain/Repaired: no documentation 07/09/2024 Drains/Sewer coming up/Repaired: no documentation 07/19/2024 Bathroom sinks/Mens bathroom sink is clogged/Repaired: no documentation 08/01/2024 Sewer/Sewer coming up/Repaired: no documentation 08/05/2024 Mens Bathroom/Mens toilet sink is clogged/Repaired: no documentation Employee #4 confirmed on 08/06/2024 that the maintenance log was incomplete and there was no documentation if repairs had been completed.”

“REGULAR FIRE AND SAFETY INSPECTIONS CFR(s): 482.41(b)(8) (6) The hospital must maintain written evidence of regular inspection and approval by State or local fire control agencies. This Standard is not met as evidenced by: 43788 Based on review of documents, Phoenix Fire Code, observation and interview, it was determined the hospital failed to ensure the fire alarm system was inspected and maintained in accordance with the Phoenix Fire Code. This deficient practice poses a risk to the health and safety of patients if the fire alarms are not functioning putting patients at risk for injury or death in the event of a fire emergency. Cross reference A0020, A0022, A0043, A0057, A0700, A0701 Findings include: A request was made for the hospital’s current fire inspection. None was provided. A request was made to the Phoenix Fire Department for the hospital’s current fire inspection. A fire inspection report dated 10/06/2023 was provided by the Phoenix Fire Department. Document titled, “City of Phoenix Fire Prevention Notice of Non-Compliance”, dated 10/06/2023 revealed: “...All Fire Code References are Phoenix City Code §15. Code Title #1: PFC901.6 Inspection, testing and maintenance. Code Text #1: Fire detection and alarm systems, emergency alarm systems, gas detection systems, fire-extinguishing systems, smoke control systems, mechanical smoke exhaust systems, and smoke and heat vents shall be maintained in an operative condition at all times, and shall be replaced or repaired where defective. Nonrequired fire protection systems shall be inspected and tested by a contractor licensed by the State of Arizona who is a current qualified contractor by the Phoenix Fire Department to work on the particular fire protection system being inspected or tested in accordance with NFPA standards, see Section 108.1. It shall be the responsibility of the owner to ensure that these requirements are met. Non-Compliant Condition #1: The fire pump has a reported deficiency on the most recent fire servicing report. Correction Required #1: The fire pump system shall be inspected and maintained in accordance with the Phoenix Fire Code...Obtain system signoffs (Green tags) for each system repaired or corrected. Required Compliance Date #1: 10/06/2023. Violation Corrected #1 In compliance on #1: NO Code Title #2: PFC901.6 Inspection, testing and maintenance. Code Text #2: Fire detection and alarm systems, emergency alarm systems, gas detection systems, fire-extinguishing systems, smoke control systems, mechanical smoke exhaust systems, and smoke and heat vents shall be maintained in an operative condition at all times, and shall be replaced or repaired where defective. Nonrequired fire protection systems shall be inspected and tested by a contractor licensed by the State of Arizona who is a current qualified contractor by the Phoenix Fire Department to work on the particular fire protection system being inspected or tested in accordance with NFPA standards, see Section 108.1. It shall be the responsibility of the owner to ensure that these requirements are met. Non-Compliant Condition #2: The fire alarm system has reported deficiencies on the most recent fire servicing report. Correction Required #2: The fire alarm system shall be inspected and maintained in accordance with the Phoenix Fire Code...Obtain system signoffs (Green tags) for each system repaired or corrected. Required Compliance Date #2: 10/06/2023. Violation Corrected #2 In Compliance on #2: NO Code Title #3: PFC901.6 Inspection, testing and maintenance. Code Text #3: Fire detection and alarm systems, emergency alarm systems, gas detection systems, fire-extinguishing systems, smoke control systems, mechanical smoke exhaust systems, and smoke and heat vents shall be maintained in an operative condition at all times, and shall be replaced or repaired where defective. Nonrequired fire protection systems shall be inspected and tested by a contractor licensed by the State of Arizona who is a current qualified contractor by the Phoenix Fire Department to work on the particular fire protection system being inspected or tested in accordance with NFPA standards, see Section 108.1. It shall be the responsibility of the owner to ensure that these requirements are met. Non-Compliant Condition #3: The kitchen hood system is past due for its annual inspection, testing, and maintenance. Correction Required #3: The kitchen hood system shall be inspected and maintained in accordance with the Phoenix Fire Code...Obtain system signoffs (Green tags) for each system repaired or corrected. Required Compliance Date #3: 10/06/2023. Violation Corrected #3 In Compliance on #2: NO....” Review of document titled, “City of Phoenix Fire Department Fire Prevention”, revealed: “...As noted in the Notice of Non-Compliance (N.O.N.C.) issued on October 6, 2023, several violations were identified that require immediate attention...Although the patients have been evacuated due to the inoperability of your chillers, your staff remains on-site. To ensure their safety and permit continued staff occupancy, the following actions must be implemented immediately: 1. Unlock All Egress Doors: All egress doors must be unlocked to ensure free and unobstructed exot for all personnel working in the building. 2. Implement A Fire Watch: A two-person fire watch is required,one for each building. In the absence of a functional fire alarm system, fire watch personnel must be designated to monitor fires and notify others in the event of an emergency. These individuals shoudl be able to communicate effectively with each other and contact emergency services (911) if necessary. Due to these outstanding fire protection issues, your operational permit has been temporarily revoked. In order to reinstate the permit and allow for occupancy of patients in the future, please address the following: 1. Restore Fire Alarm System: The fire alarm system in the Behavioral Health Center (BHC) must be fully operational. 2. Submit Evacuation Procedures: Provide detailed evacuation procedures to the fire department for review and consideration....” Employee #4 confirmed that a copy of a current fire inspection was not available.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 43788 Based on review of documents, observations, and interviews, it was determined the hospital failed to ensure the HVAC system was maintained in working order. This deficient practice poses a risk to the health and safety of patients if patient care areas are not maintained in an acceptable temperature range, and placing patients at risk of heat exhaustion, heat stroke, and death. This deficiency resulted in an Immediate Jeopardy being identified. Cross reference A0043, A0057, A0144, A0700, A0701 Findings include: The American National Standards Institute “Standard 170-2017, Ventilation of Health Care Guidelines” reveals that patient rooms, patient seclusion rooms and patient common areas should be maintained between 70 and 75 degrees fahrenheit. Hospital document titled, “Utilities Management Plan 2024”, revealed: “ ...The utility systems addressed by this plan include: ...Heating, ventilating, air conditioning (HVAC), and refrigeration ...The hospital adopts and complies with the NFPA Life Safety Code 101, 2012 Edition and the NFPA 99, 2012 Edition, and complies with current CMS requirements ... Utility Systems Maintenance: To maintain fully functioning utilities, maintenance, inspection activities and frequencies are documented and controlled in the BHC maintenance work order system. The BHC will achieve a 100% completion rate for all high-risk and infection control utility system components ...The manufacturers maintenance procedures are available in the facilities office and documented on work orders. At a minimum, the hospital utilizes manufacturers recommended standards, or the ASHE maintenance management for Health Care Facilities plans where manufacturers guidelines are not available ...Environmental Monitoring ...Appropriate maintenance of the heating, ventilation, and air conditioning systems is critical to the control of airborne contaminants. Maintenance of the appropriate pressure relationships, air exchange rates, filtration efficiencies, temperature and humidity are part of this process ....” Work orders for the HVAC system for the last 12 months were requested. Review of the work orders presented revealed 37 work orders were submitted. Review of Hospital documents titled, “Work Orders”, revealed eight work orders for the cooling system generated on 09/29/2023, 01/10/2024, 03/20/2024, 04/08/2024, 04/24/2024, 06/03/2024, 07/07/2024, and 08/06/2024 were not marked completed. The Department received notification on 08/09/2024 from Employee #41 that the cooling system at the Hospital was not functional beginning 08/08/2024 evening. The census of the Hospital on 08/08/2024 evening was 98 patients. The Hospital activated their emergency operations plan, and began discharging and transferring patients to other facilities. The transfer of patients began 8/8/25 at approximately 9:00 pm and the last patient was transferred on 08/10/24 at approximately 5:30 am. Observations on tour of the Hospital on 08/09/2024 revealed six inpatient units, and the following temperatures taken in Fahrenheit: Lobby - 100 degree Intake - 104 degree CAS unit - 84 degree AP1 unit - 82 degree AP2 unit - 94 degree AP3 unit - 93 degree AP4 unit - 93 degree AP5 unit - 85 degree Observations on tour on 08/12/2024 at 1000 hours revealed the following temperatures taken in Fahrenheit: Lobby - 87.6 degree Intake - 90.5 degree Assessment Room - 91.9 degree Assessment Room #2 - 83.7 degree AP1 unit - range 71.6-81.5 AP2 unit - range 68.4-74.5 AP3 unit - range 66.0-75.9 AP4 unit - range 78.4-84.7 AP5 unit - range 66.9-78.4 Review of temperature log revealed temperatures of units/locations on 08/08/2024, at 6:39 pm: AP5 unit - 82.5 AP1 unit - 86.9 CAS unit - 91 AP2 unit - 87 AP3 unit - 86.8 AP4 unit - 92.1 Review of temperature log revealed temperatures of units/locations on 08/09/2024, at 5:56 pm: AP1 unit - 84.3 AP2 unit - 93.6 AP3 unit - 91.6 AP4 unit - 97.6 AP5 unit - 81.6 CAS unit - 96.7 Intake - 99.8 - 105.6 Review of temperature log revealed temperatures of units/locations on 08/10/2024, at 6:00 pm: Intake - 104.8 AP1 unit - 84.0 AP2 unit - 98.4 AP3 unit - 98.5 AP4 unit - 98.9 AP5 unit - 8.0 CAS unit - 97.7 - 99.2 Review of temperature log revealed temperatures of units/locations on 08/11/2024, at 6:00 pm: AP1 unit - 85.4 AP2 unit - 86.5 AP3 unit - 85.7 AP4 unit - 87.5 AP5 unit - 83.5 CAS unit - 88.0 - 87.9 Intake - 92.9 Review of the temperature log revealed temperatures of units/locations on 08/12/2024, at 8:00 am: AP1 unit - 80.2 - 84.2 AP2 unit - 81.1 AP3 unit - 78.7 AP4 unit - 85.5 AP5 unit - 79.6 - 81.1 CAS unit - 82.2 - 83.3 Intake - 87.1 Employee #3 confirmed during an interview conducted on 08/12/2024 that the Hospital has three chillers on the building for the cooling system. Employee #3 confirmed one chiller was already not functional, and the remaining two chillers stopped operating on 08/08/2024 evening. Employee #4 confirmed the first chiller stopped operating in November 2023 and repairs had not been made.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 43788 Based on review of documents, observations, and interviews, it was determined the hospital failed to ensure the kitchen area was maintained in a sanitary and hygienic manner to protect the patients from serious adverse outcomes including illness or death from consuming contaminated food products. Findings include: The United States Food and Drug Administration publication, Food Code: 2017 Recommendations of the United States Public Health Service, Food and Drug Administration incorporated by reference in subsection (A) from R9-8-101 Food Establishments Purpose and Definition and R9-10-231 Dietary Services requires: “...2-3 PERSONAL CLEANLINESS...2-301 Hands and Arms...2-301.11 Clean Condition...FOOD EMPLOYEES shall keep their hands and exposed portions of their arms clean...Hair Restraints ...2-402.11 ...(A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLESERVICE and SINGLE-USE ARTICLES. (B) This section does not apply to FOOD EMPLOYEES such as counter staff who only serve BEVERAGES and wrapped or PACKAGED FOODS, hostesses, and wait staff if they present a minimal RISK of contaminating exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES....” The FDA Food Code 2017 which is referenced by R9-10-231 1. and R9-8 Article 1 require kitchen staff to wear some type of hair covering or restraint to prevent food from being exposed to hair. The United States Food and Drug Administration publication, Food Code: 2017 Recommendations of the United States Public Health Service, Food and Drug Administration incorporated by reference in subsection (A) from R9-8-101 Food Establishments Purpose and Definition and R9-10-231 Dietary Services requires: “...6-5 MAINTENANCE AND OPERATION Subpart 6-501 Premises...PHYSICAL FACILITIES shall be maintained in good repair. 6-501.12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. 4-6 CLEANING OF EQUIPMENT AND UTENSILS...4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch....(B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris....” Hospital document titled, “St. Luke ’ s Behavioral Health Hospital 2024 Infection Control Program, Goals, Objectives & Risk Assessment”, revealed: “ ...Goals 12. Ensure food-safety for our patients and staff in order to reduce the risk of transmission of infectious disease via foodborne pathogens ...Food should be received and stored under conditions that maintain nutritional value and minimize the risk of contamination by microorganisms, insects, rodents, and toxic substances ...Records of food and equipment temperatures must be maintained, and remediation steps developed wen systems are not in control ...Corrugated cardboard used to deliver products, should be removed as soon as possible because these boxes may deteriorate or damage the product, the product may leak, or water damage may be present; any moisture rots the boxes, and these conditions allow for pest infestation and possible damage to the product ...Any food left in the refrigerator without a discard date is discarded by the Food Nutrition employee ....” Hospital document titled, “St. Luke ’ s Behavioral Health Center Infection Control & Prevention Meeting Quarterly Meeting Minutes”, dated 04/23/2024 revealed: “ ...Dietary-Kitchen rounds, inspecting from environmental standpoint on cleanliness, check logs for cleaning and ice machine cleaning, logs for temp; will continue to monitor, no issues noted for Dietary ....” Document titled, “Diversey J-512 Sanitizer Use Overview” revealed: J-512 Sanitizer is a no-rinse sanitizer for food contact surfaces. This product is designed for use in dairies, restaurants, bars, and institutions where sanitization is of prime importance ...To sanitize pre-cleaned and portable water-rinsed, non-porous, food contact surfaces, prepare a 200-ppm active quaternary solution by adding 1 ounce of sanitizer to 4 gallons of water ...Prepare a fresh solution daily or more frequently as soil is apparent ....” Document titled, “QT-10 Hydrion Sanitizer test kits” revealed: “ ...Description. Provides a simple, reliable, and economical means to measure quaternary concentration of ammonium, chlorine, and iodine sanitizer solutions Federal, State, and Local health regulations require users of Quaternary Ammonium Sanitizer Solutions to have appropriate test kits available to verify the strength of sanitizer solutions. Sanitizer solutions are essential in the food service industry to ensure that sanitizers are at the proper concentration specified by the individual manufacturer ....” Hospital document titled, “Diversey J-512 Sanitizer” Daily testing log. Log requested, none provided. A request was made for Quat test strips manufacturer ’ s instructions, none provided. A policy regarding kitchen cleaning was requested, the facility was unable to provide. The facility provided a document titled, “Kitchen Schedule”, which contained specific cleaning assignments for each shift. The facility was unable to provide completed kitchen cleaning logs for the past year. A request was made for documentation regarding vent hood maintenance, none was provided. Observation on tour of the kitchen on 08/06/2024, Employee # 34 was requested to demonstrate to the surveyors the process when testing the sanitizer in the sinks and sanitizing buckets. . Employee # 34 demonstrated how the staff tested the concentration by dipping the Quat test strip into the solution and then comparing it to the guide on the test strips. During the demonstration, the test strips did not change color. The test was repeated twice with no change in results. Employee # 34 confirmed during an interview conducted on 08/06/2024, that there should be change in the color of the Quat test strip indicating if the sanitizer was within acceptable range for sanitizing the counters, equipment and dishes. Employee #34 confirmed that there was no documentation that the concentration of the sanitizer was being tested on a daily basis. Employee 34 confirmed during an interview conducted on 08/06/2024, that the kitchen staff had been diluting the concentration. Employee # 34 stated the staff have now been re-educated and tested on the process for mixing and testing the Diversey J-512. Sanitizer. Observation while on tour of the facility kitchen revealed three stove/oven units that were non-functioning that were encrusted with a hardened, greasy, blackened material with dried food residue and debris covering each stove top. Further observation revealed one functioning stove/oven that had dried, blackened material on the steel backsplash of the stovetop, also a blackened, greasy appearing material was noted on the burners and surrounding areas of the stovetop. Also observed on the vent hoods were dust and dirt particles with a greasy appearing substance covering the interior of the vent hood. Further observation revealed the floor of the kitchen was dirty with a dried black colored substance along the edges of the stove/ovens and refrigerators. Staff were improperly diluting the dish cleaning concentration when washing dishes, pots and pans. Also observed in the kitchen was a sink encrusted with black debris that had an empty water bottle and used gloves present in the sink. Uncovered floor drains with no protective screens present were noted in the floor of the kitchen area. Paper products were noted stored on a metal storage rack that was adjacent to and abutting the stove/oven next to an open flame on the stove. Further observation revealed a white powdery substance on the side of the walls and floor of one of the walk in coolers. Further observation revealed portable fans and portable coolers were in operation and blowing air into the food preparation as there was no functioning central air conditioning in the area. Food products were found to be stored in their original corrugated cardboard boxes in the walk in coolers, freezers and on the food prep counters. Expired food items were observed on counters and in the walk in coolers. Inspection of the floors under the stove/ovens revealed the floor was encrusted with a gray/black dusty like material, dried macaroni products,dried food residue and small black pellets that resembled rodent droppings. Employee #4 confirmed the non-functioning equipment needed to be removed from the kitchen area. Employee #4 confirmed there were no documented kitchen cleaning logs available. Employee #4 confirmed there was no functioning centralized air conditioning in the kitchen area. Employee #4 confirmed the kitchen equipment appeared to be unclean.”