Straith Hospital for Special Surgery

“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: 43001 Based on observation, interview, and record review the facility failed to provide and maintain adequate physical facilities for safety and needs for all patients, and was found not in compliance with the requirements for participation in Medicare and/or Medicaid 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 99 and 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include: See tags: A-0701 Failure to maintain a clean and sanitary environment A-0709 Failure to ensure that life safety from fire requirements were met A-0726 Failure to maintain ventilation systems and temperature controls”

“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: 43001 Based on observation, interview and record review, the facility failed to maintain cleanliness in the kitchen, cafeteria and clean supply room, and failed to maintain proper lighting levels for the scrub sink serving the operating rooms in the sterile corridor resulting in potential spread of infectious agents to patients and staff. Findings include: 1. On 4/28/2026 at 1048 during a tour of the kitchen, it was observed that approximately six, 6-inch by 6-inch floor tiles were broken and dirty underneath the dishwashing area. Staff A was asked how long the floor has been in disrepair and they stated a while, but there are plans being submitted for review to repair the various issues in the kitchen. 2. On 4/28/2026 at 1101 during a tour of the cafeteria, it was observed that the space between a vending machine and casework with storage was filthy on the floor and there was dust on top of the vending machine. Staff A was asked if housekeeping is supposed to be cleaning this area and they stated yes, housekeeping service is not done by a third party, and the team would need retraining. 3. On 4/28/2026 at 1150 during a tour of the pre and post-operative area, it was observed that multiple medical supplies were on the floor in the clean supply room, including the tubing for a Bair Hugger, which is used to wrap around patients to keep them warm during surgery. There was dust in high places in this room, on the light above the handwash sink and in the office next to the clean supply room. It was confirmed during record review that high dusting and cleaning the floors of these areas were a part of the policy and procedure. 4. On 4/29/2026 at 0940 during a tour of the surgical areas, it was observed that 3 of the 5 recessed lights above the scrub sink were burned out along with multiple other lights in the sterile corridor. Staff B asked if they knew these lights were burned out and they stated they were not aware.”

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b) Life Safety from Fire This Standard is not met as evidenced by: 45246 Based on observation, interview, and record review the facility failed to provide and maintain adequate physical facilities for safety and needs for all patients, and was found not in compliance with the requirements for participation in Medicare and/or Medicaid 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 99 and 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include: See LSC survey for the following K tags: K-321 K-324 K-761 K-781 K-918”

“VENTILATION, LIGHT, TEMPERATURE CONTROLS CFR(s): 482.41(c)(4) There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas. This Standard is not met as evidenced by: 43001 Based on observation, interview and record review, the facility failed to maintain their ventilation system in clean holding, patient rooms restrooms, janitor’s closets, as well as temperature controls in central sterile processing resulting in potential spread of infectious agents to patients and staff. Findings include: 1. On 4/28/2026 at 1154 during a tour of the pre and post operation area, it was observed that the clean holding room was negatively air pressurized with respect to the corridor by performing a tissue test at the base of the door. Staff F was asked why this room was negatively pressurized and he stated he wasn’t sure. He also stated that the mechanical contractor used by the facility did not perform a facility wide air balance after a recent project was completed and this could be the cause. 2. On 4/28/2026 at 1348 during a tour of the medical surgical unit, it was observed that the exhaust ventilation was not working in the restroom in patient room 106. Staff F was asked if they were aware that the restrooms exhaust ventilation was not working and they stated that they were not aware of the issue. Maintenance checked all of the exhaust fans on their morning rounds, but did not notice that the fan serving the medical surgical area was not working. It was confirmed that this fan served all restrooms located within patient rooms on the main floor and all restrooms did not have exhaust ventilation. 3. On 4/28/2026 at 1408 during a tour of the medical surgical unit, it was observed within the janitor’s closet, located across from room 109, that the exhaust ventilation was not working. Staff F was asked if they were aware this room’s exhaust ventilation was not working and they stated they were not aware, and it is likely that it is the same exhaust fan serving the patient room restrooms serves this area too. 4. On 4/29/2026 at approximately 0920 during a tour of central sterile processing, it was observed that the magnihelic gauge showing the static pressure drop from the corridor to the decontamination room was reading a value of 0.0 inches of water. During a review of the temperature, humidity and air pressure relationship logs for this area it showed multiple days of recordings of this magnihelic gauge reading 0.0 inches of water as well as multiple days of the temperature being out of range in the clean work room. On this log, it stated that if the magnihelic gauge value is shown at 0.0, or the temperature is out of range, the procedure is to call maintenance. Staff P said that this is what they do when they see 0.0 on the gauge, or when the temperature is out of range but there is no documentation showing that maintenance was called on any of the days where the values out of range were indicated. Staff F was asked if they ever received calls from central sterile processing for the magnihelic gauge indicating 0.0 inches of water of static pressure drop or for a temperature out of range and they stated they have never received a call for air pressure in the past, but they have adjusted the temperature in the building maintenance system to get the rooms within the proper temperature range. There was no documentation provided to the surveyor showing maintenance performed this temperature adjustment or that rechecks of temperature were performed in these areas.”