Winner Regional Healthcare Center - Cah

“MAINTENANCE CFR(s): The CAH has housekeeping and preventive maintenance programs to ensure that-- (1) All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition; This Standard is not met as evidenced by: 50715 Based on observation, interview, policy review, and manufacturer’s instructions for use (IFU) review, the provider failed to ensure that three of three Lifepak 20e’s (a defibrillator) 20 were checked daily per the manufacturer’s IFU. Findings include: 1. Observation and interview on 3/3/26 at 3:36 p.m. with registered nurse (RN) A on the medical surgical unit and emergency department (ED) revealed: *A crash cart with a Lifepak 20e defibrillator. *The charge nurses were responsible for checking the defibrillators daily in the medical-surgical unit and the ED. *A daily crash cart checklist was completed, verifying: -The staff checked the defibrillator according to the model instructions. -A defibrillator test was completed while the machine was plugged in and unplugged from a power source. -The joules (amount of electric energy delivered). -The user test. -The test strip was printed. *She stated each defibrillator would complete an auto self-test daily at 3:00 a.m. and print a test strip indicating either a pass or fail result. -That printed test strip would then be attached to the logbook located at the nursing station verifying it was completed. *She confirmed the defibrillators on the medical-surgical unit and the ED were not tested when they were unplugged, and was unsure why the staff were documenting 360 joules on the checklist, because the defibrillator had completed a self-test. *She was unaware of the manufacturer’s IFU recommendations to complete the operator’s checklist daily. 2. Observation and interview on 3/4/26 at 11:35 a.m. with RN B in the cardiac rehab department revealed: *A crash cart with a Lifepak 20e defibrillator. *She verified that the defibrillator completed a self-test daily at 3:00 a.m., and a test strip would have been printed and then placed in the logbook located in the cardiac rehab nurse’s desk. *The daily crash cart checklist was completed as performed in the medical-surgical unit and ED. *She was unaware of the manufacturer’s IFU recommendations to complete the operator’s checklist daily. 3. Review of the provider’s August 2025 Crash Carts policy revealed: *”Medical and ER [emergency room] Crash Carts must be checked daily by the charge nurse or his/her designee. *If equipment is not working, notify maintenance immediately. *Cardiac Rehab cart will be checked by cardiac rehab nurse.” *The policy did not specify the required daily checks for the defibrillator. 4. Review of the manufacturer’s 2008 IFU for the Lifepak 20 Defibrillator/Monitor Operator’s Checklist revealed: *”1. Check [the] auto test printed report for: -Self test failed. -Self test did not complete-Connect to [the] test plug. *2. Inspect physical condition for: -Foreign substances. -Damages or cracks. *3. Inspect [the] power source for: -AC power connector plugged into [the] unit and [the] AC power source; -AC Mains LED is lit. *4. Check therapy and ECG [electrocardiogram] electrodes for: -Use by date. -Spare electrodes [are] available. *5. Examine accessory cables for: -Cracking, damage, broken or bent parts or pins, and paddle surfaces for pitting. *6. Disconnect the defibrillator from [the] AC power, wait 2 seconds, press ON and check for: -Momentary SELF-TEST messages, and momentary illumination of LEDs. -Services LED is lit. -LOW BATTERY/CONNECT TO AC POWER message. *7. Check ECG printer for: -Adequate paper supply. -Ability to print. *8. Confirm [the] therapy cable [is] connected to [the] defibrillator to perform [the] cable check: -If QUIK-COMBO therapy cable is connected: --Confirm [the] test plug [is] connected to [the] therapy cable. --Press ANALYZE button. --After ANALYZING NOW message, look for REMOVE TEST PLUG message. *9. Reconnect the defibrillator to AC power and then power off [the] device.””

“PREMISES ARE CLEAN AND ORDERLY CFR(s): (4) The premises are clean and orderly; and This Standard is not met as evidenced by: 50715 Based on observation, interview, and policy review, the provider failed to ensure the premises were clean regarding: *Three of three handwashing sinks that had visible calcium/mineral buildup on the basin and fixture surfaces. *Two of two cabinets composed of damaged wood surfaces that were not cleanable and maintained in a sanitary condition. *Three of three cabinets beneath the sinks (storage areas) that had accumulated dirt, rust, and calcium/mineral buildup. *One of three base cabinets without intact caulking where the countertop met the wall to prevent water entry behind the wall. Findings include: 1. Observation on 3/3/26 at 2:38 p.m. in the nourishment room revealed: *A countertop with exposed, damaged wood. *The countertop contained a handwashing sink that contained visible calcium/mineral buildup. *Under the sink, the storage area contained accumulated dirt and rust. *The area where the countertop met the wall lacked intact caulking, allowing water to drip behind the wall and creating the potential for mold growth. 2. Observation on 3/3/26 at 2:50 p.m. in the medication room on the medical-surgical unit revealed: *A base cabinet that contained a handwashing sink with a large amount of visible calcium/mineral buildup. *The storage area under the sink contained accumulated dust, rust, dirt, and calcium/mineral buildup on plumbing fixtures. 3. Observation on 3/3/26 at 3:45 p.m. in the soiled utility room on the medical-surgical unit revealed: *A wood base cabinet containing a handwashing sink with a large amount of visible calcium/mineral buildup. *The storage under the sink contained accumulated dust, rust, dirt, and calcium/mineral buildup on the plumbing fixtures. -This storage beneath the sink was constructed of wood, making the surfaces difficult to clean and disinfect. 4. Interview on 3/3/26 at 3:55 p.m. with chief nursing officer H regarding the above findings revealed she: *Was aware of the calcium/mineral buildup on handwashing sinks. *Stated, “We have hard water here.” *Was aware the cabinets were made of wood and were difficult to clean. *Was not aware that the cabinet in the nutrition room lacked intact caulking between the cabinet and the wall, and agreed that it needed to be addressed. 5. Interview on 3/3/26 at 4:00 p.m. with housekeeping aide G regarding the above findings revealed: *The sinks were cleaned when the calcium/mineral buildup became noticeably visible. *She stated, “It depends on whether we are not short-staffed, but we try to clean them at least weekly.” *She confirmed the storage underneath the sinks were not cleaned. 6. Interview on 3/4/26 at 2:00 p.m. with infection control/employee health I regarding the above findings revealed: *She was aware that the handwashing sinks contained significant calcium/lime buildup, and these issues were forwarded to leadership. *She had notified maintenance about the lack of caulking on the countertop in the nourishment room the previous year, but the issue was not addressed. *Housekeeping were responsible for cleaning the sinks and areas beneath the cabinets. *She agreed that wood surfaces cannot be adequately cleaned or disinfected. *She agreed these conditions had the potential to harbor microorganisms and increase the risk for contamination and infection transmission. 7. Interview on 3/4/26 at 3:00 p.m. with supervisor-housekeeping F revealed: *When sinks contained significant calcium buildup, the staff were instructed to use Lime-A-Way (a cleaning product used to dissolve and remove tough mineral deposits caused by hard water) at least weekly. *The cabinets under the sinks were not cleaned. She stated, “We do not do any cleaning of the cabinets under the sink.” *The sink in the medication room was only cleaned when the nursing staff were present. *She confirmed there were no provider policies indicating a cleaning process for rooms other than patient rooms. 8. Observation and interview on 3/5/26 at 8:25 a.m. with maintenance assistant D and chief executive officer E in the nourishment room, medication room, and soiled utility room located on the medical-surgical nursing unit revealed: *They agreed the three sinks contained visible calcium/mineral buildup. *They agreed the two cabinets had damaged wood and were not cleanable or maintained in good condition. *They agreed the three cabinets beneath the sinks contained accumulated dirt, rust, and calcium/mineral buildup. *They agreed the cabinet located in the nourishment room lacked intact caulking where the countertop met the wall, allowing water to enter behind the wall, creating the potential for mold growth. The provider did not have any policies or procedures for cleaning areas other than patient rooms.”