Petaluma Valley Hospital

“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: 50168 Based on observation, interview and document review, the facility failed to provide a clean and sanitary environment for 2,092 patients admitted to the hospital and 2,324 surgical cases over a period of 12 months in accordance with the facility’s policy, procedures, and national standards of practice when: 1. The facility failed to ensure the facility was free from tape, adhesive, adhesive residue, and peeling stickers left on surfaces and walls in Sterile Processing Department (SPD, an area in the facility used to clean, disinfect, sterilize, store, and maintain the reusable and surgical medical instruments), Endoscopy reprocessing room, Pre-Operative and Post-Operative Units, Emergency Department, and Medical Surgical Department (Refer to A- 0749); 2. The facility failed to ensure infection control practices were performed in accordance with nationally established standards for instrument cleaning and environmental cleaning in the Endoscopic Storage and the Decontamination Room (Refer to A-0749); 3. The facility failed to provide documented evidence for daily cleaning of the Operating Rooms and Sterile Processing department (Refer to A- 0750); 4. The facility failed to ensure an ice machine in the Post-Operative unit was being cleaned and maintained according to policy and procedure (P&P) and manufacturer’s instructions for use (IFU) (Refer to A-0749); These failures had the potential to expose surgical and hospitalized patients to germs that cause disease. The cumulative effect of these systemic problems resulted in the facility’s inability to comply with the statutorily mandated condition for infection control.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 51078 Based on observations, interviews and record review, the facility’s infection prevention and control program (IPCP) failed to ensure a clean and sanitary environment for 2,092 patients admitted to the hospital and 2,324 surgical cases over a period of 12 months in accordance with the facility’s policy, procedures, and national standards of practice for infection control to prevent and control infections among patients, personnel, and visitors when: 1. The IPCP failed to ensure the facility was free from tape, adhesive, adhesive residue, and peeling stickers left on surfaces and walls in the Sterile Processing Department (SPD - an area in the facility used to clean, disinfect, sterilize, store, and maintain the reusable and surgical medical instruments), Endoscopy reprocessing room, recovery room (RR), preoperative (PO) area, emergency department (ED), and the medical surgical (MS) unit. 2. The facility failed to ensure the flooring in the SPD was repaired/replaced when cracks, rips, and tears were identified, 3. The storage procedures for high level disinfection (HLD, a process that kills all microorganisms except for a small number of bacterial spores) instruments were not implemented in accordance with the manufacturer’s instructions for use (IFU) and national standards for six (6) of seven (7) sampled endoscopes, 4. The facility failed to ensure the SPD decontamination room (an area where dirty medical equipment is cleaned) was set up and maintained in accordance with facility adopted nationally recognized infection control guidelines, 5. The facility failed to ensure an ice machine in the RR was cleaned and maintained according to policy and procedure (P&P) and IFU. These failures resulted in unsafe healthcare practices and had the potential to result in cross-contamination (the process by which germs are unintentionally transferred from one substance or object to another, with harmful effect) and increased the risk for the spread of communicable diseases (an illness that can spread from one person to another), potentially adversely affecting the health and safety of patients being cared for in the facility. Findings: During a concurrent facility tour and interview on 10/20/25 at 10:10 a.m., with the Infection Preventionist (IP - responsible for preventing and decreasing infection within the facility), the IP stated the facility adhered to the following nationally recognized guidelines: A. APIC - Association for Professionals in Infection Control (professional association for infection prevention). B. AORN - Association of Perioperative Registered Nurses (professional organization which publishes evidence-based guidelines which define the standards that help keep healthcare workers and surgical patients safe). C. AAMI - Association for the Advancement of Medical Instrumentation (an organization for advancing the development, and safe and effective use of medical technology). D. CDC - Centers for Disease Control and Prevention (the national public health agency of the United States). 1. During a concurrent observation and interview on 10/20/25 at 10:22 a.m., in the SPD prep and pack area (a clean work area in the SPD), with the IP, and the Perioperative Manager (PM, a nurse leader who makes sure everything goes smoothly before, during, and after surgery), several black streaks were observed on the floor adjacent to the Autoclave (a machine used to destroy germs on equipment). The PM validated the black marks and stated it was “adhesive residue”. The PM stated the floor was not “up to standard” and adhesive residue could not be sanitized. During a concurrent observation and interview on 10/20/25 at 10:38 a.m., in the sterile storage area, with the IP, a filing cabinet with two (2) partially peeled labels, a storage bin with three (3) partial peeled paper labels and adhesive residue, and a storage rack with two (2) partially peeled paper labels and adhesive residue were observed. The IP validated the observations and stated peeling labels, and sticky adhesive residue could not be properly cleaned and created a cross-contamination risk that could lead to spread of infectious particles in the facility. During a concurrent observation and interview on 10/20/25 at 11:00 a.m. with the Nurse Educator (NED) 1, a tour of the PO and RR areas of the facility were performed. NED 1 confirmed the following areas of the facility showed improper use of adhesive tape to secure items and to post paper documents without plastic covers: a. A section of a handrail, approximately 12 x 8 inches in size, in a hallway between the lobby and the PO patient care area was broken and held together with large pieces of white adhesive and the edges contained areas of black adhesive residue. b. A cabinet in the desk area between the PO and the RR had paper documents that were affixed to the cabinet door with adhesive tape with peeling edges and contained several areas of adhesive residue. c. An ice machine in the RR area had a large yellow piece of paper affixed to the top of the machine with several pieces of adhesive tape and ice machine surfaces had visible adhesive residue. d. A paper sign in the patient restroom in the RR was affixed to the wall behind the toilet with adhesive tape. e. An automatic hand sanitizer container in the RR was attached to the wall with the bottom portion secured with a large white piece of adhesive tape. During a concurrent observation and interview on 10/20/25 at 1:32 p.m. with the Manager of the Emergency Department and Intensive Care Unit (MEDICU), a tour of the ED was conducted. The MEDICU confirmed the following areas showed improper use of adhesive tape to post paper documents without plastic covers, adhesive residue, and peeling stickers. a. The glass cabinet doors in the trauma bay had several documents affixed with adhesive tape and several areas of adhesive residue. b. The door leading to a supply room had several documents affixed with adhesive tape and had several areas of adhesive residue. c. A medication refrigerator had several documents affixed with adhesive tape and had several areas of adhesive residue. d. The top front corners of the crash cart (a wheeled container carrying medicine and equipment for use in an emergency) had two adhesive stickers that were peeling and contained white adhesive residue around the edges. e. At the nurse’s station was a large piece of paper affixed to the counter with adhesive tape. During a tour of the Endoscope Reprocessing Room on 10/21/25 at 9:12 a.m., with the IP an endoscope reprocessing machine (a special machine that cleans and disinfects medical cameras) with a partially peeled label was observed. The IP validated the observation. During a concurrent observation and interview on 10/22/25 at 8:54 a.m. with NED 1, a tour of the MS unit was conducted. NED 1 confirmed the following areas showed improper use of adhesive tape to post paper documents without plastic covers. a. Several documents were affixed to a large dry-erase board in the main hallway with adhesive tape and several areas of the board contained adhesive residue. b. Several paper documents were found affixed with adhesive tape to the window on the outside of the supply room adjacent to the nurses’ station. c. Several paper documents were found affixed with adhesive tape to the cabinets inside the supply room adjacent to the nurses’ station. During a concurrent interview and document review on 10/22/25 at 9:56 a.m. with the IP, 17 pictures were reviewed showing the areas where unprotected paper (no plastic or wipeable surface), stickers, adhesive tape and adhesive residue had been observed in the facility’s PO area, RR, ED, and MS unit. The IP stated all the pictures indicated inappropriate use of tape, stickers, and paper, and the result was the increased potential for microbes (germs) to grow and flourish by not being able to wipe down these surfaces or clean the areas properly. The IP further stated this microbe growth could lead to hospital acquired infections (HAI, infections that develop in a healthcare setting) and put everyone at risk for the spread of germs including patients, staff, and visitors. During an interview on 10/22/25 at 11:17 a.m. with the Environmental Services (the department or team within a healthcare facility responsible for maintaining a clean, safe, and hygienic environment for patients, staff, and visitors) Director (EVD), and an Environmental Services employee (EVS) 1, EVS 1 stated if she found something difficult to clean in SPD, she notified the supervisor, and a work order was placed. The EVD stated EVS staff had tools and cleaners to remove adhesive residue, and it was an expectation that adhesive residue be removed during daily cleaning. The EVD stated he was unaware of the adhesive residue in the SPD prep and pack area and was not aware of a work order to remove the adhesive residue. A review of the facility P&P titled “Cleaning of Sterile Areas - Surgical Suites and SPD”, dated 5/23, indicated, “Purpose: to clean and disinfect the Surgical Suites and Sterile Processing Department (SPD) in an effort to reduce the spread of infection and thereby maintaining a clean, safe environment for patients and staff”. A review of the facility P&P titled, “2025 Infection Prevention Program Plan”, dated 5/25, indicated, “ ...Purpose ... [Name of facility] will maintain an ongoing Infection Prevention Program designed to prevent, control, and investigate infections and communicable diseases among patients, health care workers, and visitors. The plan shall comply with the Joint Commission Hospital Accreditation Standards (IC.01.05.01) and California Department of Public Health infection prevention regulatory requirements ....2. Scope of Practice ...The [name of facility] Infection Prevention Specialist shall have the authority to institute appropriate surveillance, prevention, and/or control measures when any condition exists that could result in the spread of infection within the hospital ... 6. Surveillance Plan ...Conduct or facilitate infection prevention, environment of care, and isolation rounds ...10. Mitigation ... [Name of facility] uses evidence-based national guidelines ...” A review of ANSI/AAMI “ST79: 2017 - Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities”, indicated, “ ...3.3.5 General facility design requirements: All surfaces (e.g., floors, walls, ceilings, cabinets) should be durable, smooth, and cleanable ... Surfaces that are durable, smooth, and cleanable allow for ease of cleaning and assist in preventing buildup of dirt and debris in crevices ...” According to the CDC, in an undated article from the Environmental Cleaning Procedures | HAIs | CDC titled, “Environmental Cleaning Procedures,” the article indicated, “ ...The clean area (used for storing reprocessed equipment) should: Have shelves that are smooth, non-porous, and easy to clean. Be protected from water and soil, dirt, and dust ...” According to the CDC, in an undated article, retrieved from https://www.cdc.gov/infection-control/hcp/environ mental-control/appendix-c-water.html, the article indicated, “Microorganisms have a tendency to associate with, and stick to surfaces ... These adherent organisms can initiate and develop biofilms [a thin layer of bacteria that adheres to the surface] ...” 2. During a concurrent observation and interview on 10/20/25 at 10:22 a.m., in the SPD prep and pack area with the IP, and the PM, a corner of the floor/wall was observed chipped, cracked, rough, and with a piece missing. The PM and the IP validated the damaged flooring, and the PM stated the flooring was not up to national standards and could not be sanitized. During a concurrent observation and interview on 10/20/25 at 1:55 p.m., in the SPD decontamination room with the IP, the floor was observed to have an approximately 6-inch crack and rip adjacent to the decontamination sink drain. The IP validated the cracked, ripped flooring. During a concurrent interview and record review on 10/22/25, at 9:20 a.m., in an administrative office, with the IP and the Sterile Processing Supervisor (SPS), photos of the SPD prep and pack area, taken 10/20/25 at 9:55 a.m., and photos of the decontamination room taken 10/20/25 at 1:48 p.m. were viewed. The SPS validated the chips, tears, rips, and cracks in the flooring and stated the flooring did not meet standards. The SPS stated she had expressed her concerns to the engineering department and completed a work order. The IP stated, “Cracks in the floor cannot be sanitized,” and explained bacteria can grow in broken flooring. The IP stated, “Bioburden can fall into the cracks and flourish and live”, and the broken cracked flooring cannot be sanitized. During a concurrent interview and document review on 10/22/25, at 10:40 a.m., in an administrative office, with the Area Facilities Director (AFD - responsible for all building and systems upkeep oversight), and the Chief Engineer (CE - responsible for ensuring the building and facility systems work safely and correctly). AFD validated he was aware that several work orders regarding the cracked flooring in the SPD had been submitted and stated the “flooring project was on their radar”. AFD shared an email dated 1/2/25, that indicated “Subject [facility name] SPD decontamination ...Did a walkthrough on Monday of the [facility name] decontamination area, here is a summary of what is needed - Replace Flooring....” The AFD stated the flooring had not been replaced. AFD validated he had been aware that the flooring had needed repair for over nine months and stated nine months “was too long to address an issue”. A review of the facility’s “Quality Control Minutes” from 6/25 through 9/25 indicated there was no discussion about the damaged flooring and no action plan to replace the flooring. A review of the facility’s P & P titled, “Cleaning of Sterile Areas - Surgical Suites and SPD”, dated 5/23, indicated, “Purpose: to clean and disinfect the Surgical Suites and Sterile Processing Department SPD in an effort to reduce the spread of infection and thereby maintaining a clean, safe environment for patients and staff ...” A review of ANSI/AAMI “ST79: 2017 - Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities”, indicated “3.3.5 General facility design requirements: All surfaces (e.g., floors, walls, ceilings, cabinets) should be durable, smooth, and cleanable. Unless otherwise stated ...all processing work areas should conform to the following recommendations. Surfaces that are durable, smooth, and cleanable allow for ease of cleaning and assist in preventing buildup of dirt and debris in crevices. Floors should be level (i.e., should have no ridges or bumps); be constructed of non-particulate or non-fiber shedding materials that will withstand daily or more frequent wet cleaning and the application of chemical cleaning agents ...” 3. During a concurrent observation and interview on 10/20/25 at 11:02 a.m., in the endoscope storage area, with the IP and the PM, seven (7) endoscopes were observed hanging vertically with air channel tubing attached to each endoscope. For six of seven endoscopes, the air channel tubing was touching other air channel tubing. Scopes 1,2,3 and 4, and the air channel tubing connected to each scope were hanging together touching. Scopes 5 and 6 were hanging with their air channel tubing touching. The IP validated the observation. The IP stated the facility followed AAMI ST 91 for endoscope storage and stated the endoscopes were not hanging freely when the air channel tubing was touching. During a concurrent observation and interview on 10/20/25 at 11:10 a.m., in the endoscope storage area, with the Endoscopy Technician (ET), in the presence of the IP, the ET validated the tubing was touching and stated the tubes should not be touching, but she used them anyway. During an interview on 10/20/25 at 11:15 a.m., in the endoscope storage area, with the PM, the PM stated it was not okay to use endoscopes that were touching. The PM stated touching endoscopes had the potential to spread infection. A review of the facility’s P & P titled, “Endoscope Pre-Cleaning and High-Level Disinfection,” dated 10/20/20, indicated, “Policy ... It is the policy of the SPD that Endoscope reprocessing protocols are the minimum basic steps for cleaning, high-level disinfecting, drying, and storing of Gastrointestinal endoscopes. All endoscopes reprocessed at all facilities will be conducted in accordance with Manufacturer’s Instructions for Use (IFU) and in accordance with specifications recommendations supplied by the manufacturer ...10. Storage: a. Endoscopes shall be stored in a manner that will protect it from contamination ...” During a concurrent interview and document review on 10/21/25 with the IP, an e-mail from the endoscope manufacturer infection prevention consultant (IPC), dated 10/21/25, was reviewed. The document indicated “you want to try and avoid the scopes and tubing from touching as much as possible ...” A review of ANSI/AAMI “ST91:2021 Flexible and semi-rigid endoscope processing in health care facilities,” dated 2022, indicated, “11 Storage of processed endoscopes: 11.1 General considerations, Effective storage of flexible and semi-rigid endoscopes is an important aspect of processing to ensure the devices are safe for patient use because it helps provide protection of the endoscopes and accessories and prevents recontamination of the devices ...11.2.1 Storage procedures: Endoscopes are to be stored in an area that is clean, well-ventilated, and dust-free in order to keep the endoscopes dry and prevent exposure to potentially hazardous microbial contamination (unwanted germs on clean or sterile equipment that could make people sick). They should be stored in a manner that will protect them from damage or contamination ...There should be sufficient space between and around endoscopes to prevent them hitting one another ... Rationale: When flexible and semi-rigid endoscopes are hung in the vertical position, coiling or kinking is prevented. Following recommended storage practices facilitates drying and decreases the potential for contamination ...” 4. During a tour of the decontamination room on 10/20/25 at 1:55 p.m., with the IP and the Sterile Processing Technician (SPT) the following concerns were identified: a. The eyewash station was attached to the decontamination sink. b. Approximately 10 instrument stringers (a metal holder used to keep surgical instruments open during washing and sterilizing) were hanging on the eyewash station. c. There was a contaminated instrument cart with dirty instruments and equipment stored next to the ultrasonic machine, which was on a portable supply cart holding brushes for cleaning instruments. d. The ultrasonic machine had a hose that drained directly into a hopper (a big powerful sink used to get rid of dirty water or waste) without a splash guard (a barrier to protect workers and clean surfaces from getting splashed with dirty water or germs). e. There was no handwashing sink in the decontamination room. f. There was no designated space for donning (putting on) and doffing (removing) personal protective equipment (PPE - specialized clothing such as gowns, gloves, masks, shoe covers, hair covers to wear to act as a barrier for potential infectious materials, chemicals, or physical hazards that could cause injury or illness). These observations were validated by the SPT and the IP. During an interview on 10/20/25 at 1:57 p.m., with the SPT in the decontamination room, the SPT stated the facility followed AAMI ST 79 for decontamination. The SPT stated the decontamination room was not “ideal” and there was not enough space for storage. During an interview on 10/20/25 at 2:10 p.m., in an administrative office with the IP and the PM, the IP validated decontamination room observations with the PM and stated the eyewash station should not be on a decontamination sink because of the “potential for infectious material to splash onto staff”. The IP stated stringers hanging on the eyewash station could interfere with the use of the eyewash station. During an interview on 10/21/25 at 3:02 p.m., in an administrative conference room with the IP, and the Infection Control Manager (ICM), the IP stated it was her expectation that the facility followed best practice for infection control, and the decontamination area did not meet minimum standards set forth in AAMI. The IP stated she was aware of the issues in the decontamination area. During a concurrent interview and record review on 10/22/25, at 9:20 a.m., in an administrative office, with the IP and the SPS, photos of the decontamination room taken on 10/20/25 at 1:51 p.m., were viewed by the SPS. The SPS stated there was no worktable or workstation per AAMI standards and “there should be”. The SPS stated there was no separate handwashing sink, staff used the first sink for handwashing but that was not a AAMI standard. The SPS stated there was no space to put on and take off PPE effectively. The SPS reviewed the AAMI ST 79 , and stated to comply with AAMI standards the decontamination room needed to have a handwashing sink, the eyewash station moved from the decontamination sink, a flat surface or workstation, and proper storage for clean items. The SPS and IP stated the decontamination room did not meet AAMI standards. During an interview on 10/22/25 at 9:57 a.m., in an administrative office with the AFD and the CE, the AFD stated during environment of care (EOC) rounds they had not noticed the ultrasonic machine drain hose. The AFD stated the ultrasonic machine was not “hard piped” and stated the ultrasonic IFU indicated a suitable drain was required. The AFD stated the hose draining into a hopper was not a “suitable drain”. The AFD validated there was no splash guard on the hopper and stated the lack of splash guard “added to the infection control concerns” in the facility. A review of the facility’s P&P titled, “2025 Infection Prevention Program Plan,” dated 5/25, indicated, “ 1 Purpose [name of facility] will maintain an ongoing Infection Prevention Program designed to prevent, control, and investigate infections and communicable diseases among patients, health care workers, and visitors. The plan shall comply with The Joint Commission Hospital Accreditation Standard (IC.01.05.01) and California Department of Public Health infection prevention regulatory requirements ...2. Scope of Practice ... [Name of facility] Infection Prevention Specialist shall have the authority to institute appropriate surveillance, prevention, and/or control measures when any condition exists that could result in the spread of infection ...” A review of an IFU titled, “[Company name] SI Digital, User Manual”, dated 7/08, indicated, “1. Unpack the machine and place it on a sturdy, level surface. The unit should be positioned within 1.83m [meter] of a 13A [type of water line]mains supply and, if possible, a suitable drain and hot and cold-water supplies ...” A review of ANSI/AAMI “ST79: 2017 - Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities”, indicated, “3.3.5 General facility design requirements: All surfaces (e.g., floors, walls, ceilings, cabinets) should be durable, smooth, and cleanable. Unless otherwise stated ...all processing work areas should conform to the following recommendations. Surfaces that are durable, smooth, and cleanable allow for ease of cleaning and assist in preventing buildup of dirt and debris in crevices ...3.3.6.1 Decontamination area/room 3.3.6.1.1 Design considerations: The decontamination area/room should ... have three-section sinks that ...include attached solid counter or adjacent work surfaces on which to place soiled and clean items separately ...3.3.6.1.2 Space consideration ...The decontamination room/area should include designated space for ...b) storage of PPE, cleaning supplies ...3.2.1.2 Decontamination area/room ...Design considerations should include ...j) personal comfort and safety requirements, including a system to separate soiled ...and other such supplies from extra supplies in storage so that personnel not wearing PPE can acquire the supplies for other areas without being exposed to contaminated items, PPE requirements, including space for donning and removing, disposal and storage ... k) quality and placement of hand sanitizers and sinks designated only for hand hygiene ...3.2.2 Functional workflow patterns: The sterile processing department/area should include a) functionally separate areas within the decontamination area/room for ...d) adequate space for all functions and equipment, with related functions in close proximity to maximize efficiency; ...e) systems to contain contaminants and minimize employee exposure to bloodborne and other potentially infectious organisms; and f) a workflow pattern that allows items to move progressively from being contaminated to being safe to handle ...Rationale: Adherence to these functional design recommendations helps contain potential contaminants within a particular portion of the decontamination are and thus helps prevent cross-contamination or recontamination ...3.3.7 Emergency eyewash/shower equipment ....Eyewash stations should not be in a location that requires flushing of the eyes in a decontamination sink ...” A review of AORN “Guideline for Care and Cleaning of Surgical instruments (2025),” indicated, “4. Sterile Processing Area ...4.3 Do not clean or decontaminate instruments in sinks where eyewash stations are located or hand hygiene is performed. Cleaning soiled instruments can contaminate the sink and faucet, which can contaminate the person using the sink for clean activities, such as hand washing, surgical hand antisepsis, or flushing their eyes. 4.4 the decontamination area must contain an eyewash station and a dedicated hand hygiene sink. The Occupational Safety and Health Administration (OSHA) requires that an eyewash station be provided in areas where chemicals that are hazardous to eyes are located. Hand hygiene facilities are required by OSHA for use after removal of PPE ...4.5 Equip the decontamination area with ...storage space for PPE and cleaning supplies ...” 5. During a concurrent observation and interview 10/20/25 at 11:18 a.m. with the NED 1 in the RR, a small ice machine was observed sitting on the counter. NED 1 stated she was “pretty sure” the ice machine was intended for patient consumption, and she did not know who was responsible for the cleaning and maintenance of the machine. During an interview on 10/21/25 at 2:46 p.m. with Registered Nurse (RN) 5, RN 5 stated the ice machine sitting on the counter in the RR was used to give patients ice chips and to put in their water while recovering from surgery. During an interview on 10/21/25 at 2:50 p.m. with the PM, the PM stated the ice machine was cleaned once a month by staff in the RR, but she could not provide any cleaning logs or evidence of staff cleaning the ice machine. During an interview on 10/21/25 at 3:03 p.m. with the IP, the IP stated the small ice machine in the RR was purchased in October of 2024. During an interview on 10/22/25 at 10:41 a.m. with the IP, the IP stated the expectation was for the ice machine in the RR to be internally and externally cleaned according to the facility’s P&P and the outcome of not doing so could have the potential to make the entire hospital population sick including patients, visitors, and staff. During an interview on 10/22/25 at 10:55 a.m. with the AFD. AFD stated the Engineering Department oversaw all cleaning and maintenance of the ice machines in the hospital. AFD stated the ice machine in the RR was put into use without their knowledge. AFD stated the ice machine was not properly checked and added to the cleaning schedule when installed. AFD stated the ice machine had not been cleaned or serviced by the engineering department since it was put into use over a year ago. The AFD further stated the outcome of not performing the proper internal cleaning of an ice machine could lead to Legionella (a bacteria that causes Legionnaires’ disease, a type of pneumonia) and calcium build up which could negatively affect the health and safety of all patients, staff, and visitors at the facility. During a review of the facility’s P&P titled, “Ice and Ice Machine, 535”, dated 5/23, the P&P indicated, “Equipment is used and maintained in a safe and sanitary manner ...Ice supply is treated as food. It is kept clean, safe, and sanitary. Methods used for making, storing, and dispensing ice do not allow contamination to occur ...The exterior surfaces of the ice machines in the ...units are cleaned and sanitized by Nursing or EVS ...The inside of the ice machines are maintained by Engineering through semi-annual cleaning and sanitizing following manufacturer guidelines. Record of ice machine preventative maintenance is retained by Engineering”. During a review of the (name of manufacturer) IFU titled, “Ice Maker Use & Care”, undated, the IFU indicated, “Clean ...Change water in the water reservoir every 24 hours to ensure reasonable hygiene level ...System Cleaning/Sanitizing Procedure ... ...perform monthly cleaning to remove mineral deposits”.”

“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: 50168 Based on observation, interview, and record review, the hospital failed to maintain a clean and sanitary environment for 2324 patients who had surgery at the hospital over the previous 12 months when terminal cleaning (set of thorough cleaning procedures done at the end of the day) logs had missing documentation of cleaning in the Sterile Processing Department (SPD, responsible for washing and sterilizing surgical equipment prior to reuse), and four of five Operating Rooms (OR). This failure created an increased risk of infections for the patients having surgery in the hospital in the last 12 months. Findings: During a concurrent interview and record review on 10/22/25 at 10:50 am with Infection Preventionist (IP) terminal cleaning logs for SPD and ORs were reviewed. IP stated terminal cleaning was required OR rooms even if rooms had not been used. OR terminal cleaning log was missing initials verifying cleaning for ORs 1-4 on 8/8/25. IP stated 8/8/25 was a Friday, and there were OR cases on that day. IP stated the ORs should have been terminally cleaned. Logs were reviewed for cleaning of the SPD. The terminal cleaning log for the decontamination area (where surgical instruments are cleaned prior to being sterilized) and the log for the clean room (a room where instruments are wrapped and packed after washing) were missing initials for 4/4/25. IP confirmed that cleaning logs were missing initials to verify cleaning had been done. IP stated rooms in which surgical equipment is cleaned after use and reprocessed for further use need to be cleaned daily. During a review of a facility policy titled, “Cleaning of Sterile Areas-Surgical Suites and SPD,” dated 5/23, the policy indicated that for terminal cleaning “Environmental Services Staff (EVS) .... sign and date the terminal cleaning log.””