The Medical Center of Southeast Texas

“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: 29191 Based on observations, record review, and interviews, the facility failed to maintain a clean and safe environment for the patients it served. The facility failed to ensure proper air exchange and ventilation in patient rooms due to non-functioning Chillers, dirty, and clogged air conditioner filters. The facility failed to ensure ceiling tiles were in good repair on the fourth floor nursing hallways, which consisted of North, South, East, and West halls, to prevent plaster from falling into the patient rooms. Cross Refer to TAG A 0701 It was determined that this deficient practice created an Immediate Jeopardy situation and placed patients at risk of potential harm, serious injury, and subsequent death. These failed practices had the potential to affect all patients admitted to the facility.”

“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: 29191 Based on observations, record review, and interviews, the facility failed to maintain a clean and safe environment for the patients it served. The facility failed to ensure proper air exchange and ventilation in patient rooms due to non-functioning Chillers, dirty, and clogged air conditioner filters. The facility failed to ensure ceiling tiles were in good repair on the fourth floor nursing halls, which consisted of North, South, East, and West halls, to prevent plaster from falling into the patient rooms. A review of the complaint/grievance records for May and June 2026 revealed that a complaint was filed on 06/08/2026. “The patient stated that room was hot and nobody attempted to fix it and left AMA. She stated that staff did not help her gather and bring her belongings to the car. She then stated that she realized that her IV was not taken out of her arm.” The hospital was cooled by 17 chillers. (A large device used in big buildings to make cold water for air conditioning.) During a tour of the fourth floor on 07/13/2026, starting at 10:00 AM with Staff #1,#2,#3, and #4, the following sanitary and unsafe conditions were observed: The fourth floor consists of North, South, East, and West Hallways. * Chiller #14 supplies air conditioning to the North and East hallways. * Chiller #15 supplies air conditioning to the South and West hallways * In patients’ rooms 419, 420, 422, 423, 424, 425, and 426 (North Hallway), observed large brown water stains with black coloration within the water stains. There were patients currently in the rooms. * Room 419 was blocked and marked due to plumbing issues. Observed that a black substance had backed up in the patient’s shower and was still present. The leadership reported this had happened a couple of days ago. No confirmation was obtained on exactly when the plumbing issue occurred. * The air conditioning vent at the end of the North hallway had condensation dripping to the floor. * Rooms 431, 432, 433, 434, 435, 436, 437, 438, 439, 440, and 441 were hot and humid on the West Hallway. Rooms 435, 436, 437, and 438 observed large brown water stains with black coloration within the water stains. These rooms had been marked and blocked by the leadership. * The South and East Hallway on the fourth floor was marked closed with an Infection Control Construction permit 2026-3 dated 06/16/2026 and expiration date of 07/26/2026. There was no airflow in these hallways because AHU#15 (Chiller) was not working. “The AHU#15 (Chiller) needed - 4 new Spring Isolators - New Blower wheel - 1 New Inlet Cone - Miscellaneous material - labor to replace” The cost for the AHU#15 (Chiller) parts was $13,975.00, which had not been approved until the surveyor started investigating on 07/13/2026. The invoice showed a date of 06/17/2026. Leadership reported that it would be 3-4 weeks before the parts would be available. The air conditioning supplied by chiller #15 to the South and West hallway, which were the hallways that were hot and humid on the fourth floor, was going to cost $80.000. The part was a coil and had to be built because the chillers are so old that the company does not carry the part anymore. The facility leadership had requested the money from the corporate office, but the repair of the coil had not been approved until 07/13/2026 at 11:45 AM, after the surveyor had requested proof that the chiller was going to be fixed. * A tour of the Fourth floor East Hallway revealed numerous missing ceiling tiles from the main hallway. During the survey, an engineer from the Health and Human Services Commission, Architectural Review Unit, was on site. The engineer climbed a ladder and accessed the air conditioning duct system. The insulation around the duct was soaked with water, and there was a black substance seeping through the insulation. The engineer reported that condensation was dripping from the chiller down the ducting system. The Engineer reported that all the insulation needed to be replaced. * There were patients currently on the North Hallway with sanitary issues observed, and air conditioning issues on South, East, and West hallways. During the tour on the third floor at 11:00 AM, sanitary issues with the following rooms were observed. * Rooms 301, 304, and 306, which were located on the East hallway, had large brown water stains with black coloration within the water stains. * There were multiple large brown water stains down the main hallway of 3 East. During the tour with an engineer from the Health and Human Services Commission, the Architectural Review Unit went inside the AHU #14 room, which was located on the fourth floor at the end of the North hallway. The floor was covered in a black substance. The wall inside the AHU #14 that connects to a patient’s room was bowing outward, the plaster was peeling off the wall, and there was a black substance running up the plaster. The ducting running from the chiller (AHU #14) to the ducting that cools the North Hallway was covered in a black substance. Behind the chiller in the same room was the vent where clean air is pulled in from the outside and enters the chiller. The Engineer opened the small door where the vent was located; the fresh, clean air was being pulled across debris and silts particles on the shelf and entering the chiller. The chillers have pre- and post-filters. The engineer reported that the pre-filters were not the correct size and were covered in black substance. There are approximately 16 post filters in the chiller, and the filters were dirty with black substance. The filters are white, but these filters were black colored. The plant operations staff was asked when the filters were changed. The plant operations could not recall when the filters were changed. Patients were currently being cared for on the North Hallway. The tour continued to the outside, where a mobile air conditioner was supplying air conditioning to the first floor, where surgery, intensive care, radiology, laboratory, and emergency services were located. The fence that secures oxygen tanks was unlocked, and one of the cages holding oxygen did not have a lock. The gate lock was a rusted hole, and no lock existed. There was trash all along the sidewalk to the oxygen fence/cage, and trash was located along the dock to the backside of the hospital entrance. Overgrown grass and weeds were observed along the back dock. Observed broken furniture along the sidewalk. The outside of the hospital had an unclean appearance. An interview with leadership members #1, # 2, 3, and 4, and #10 on 07/13/2026 at 5:30 PM acknowledged all the sanitary issues found and observed during the tour of the hospital.”

“The purpose of this unannounced visit was to investigate complaint # TX00564281 with the allegation of a non-functional air conditioner for the entire fourth floor and caved in ceiling and mold on the fourth floor. Based on observations, interviews, and records reviews conducted during the investigation, it was determined that the allegation air conditioning system malfunction was substantiated. The black spotting around the ductwork was substantiated. The caved in ceiling is unsubstantiated. A Life Safety Code (LSC) compliant investigation was conducted at the facility on July 13, 2026. An entrance conference was conducted at noon of July 13, 2026 with the Hospital CEO, CNO, and Quality Director to discuss the purpose of the LSC compliant and the survey process. An opportunity was provided for questions and discussion. The LSC survey was conducted under the authority of Chapter 2 of the State Operations Manual, Appendix A, Acute Care Hospitals, 42CFR482 to determine the Hospital’s compliance. A LSC exit conference was conducted on the afternoon of July 13, 2026, with the Hospital CEO, CNO, and Quality Director. The preliminary findings of the survey and the next steps in the survey process were explained. An opportunity was provided for questions and discussion. Note: The CMS-2567 (Statement of Deficiencies) is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. Any discrepancy in the original deficiency citation(s) will be reported to the Dallas Regional Office (RO) for referral to the Office of the Inspector General (OIG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Survey Agency (SA) should be notified immediately.”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 28433 Based on observations during the tour of the facility on July 13, 2026, with the Quality Director, the facility failed to maintain the temperatures on the 4th floor, where patients in sleeping beds are located. Based on observations during the tour of the facility on July 13, 2026, with the Quality Director, the facility failed to maintain the HVAC duct system as numerous black spotting are occurring in the air ducting panels. Inspection of Air Handling Units (AHU) 12 and 13 serving the 4th floor wings revealed that the 2 AHU had non-standard pre-filters and one had no pre-filters at all, the fresh air intake sources were full of debris and silts Inspection of Air Handling Units (AHU) 14 and 15 serving the 3rd floor wings revealed that the 2 AHU had non-standard pre-filters and the fresh air intake sources were full of debris and silts. The cooling coils fins on both the 4th and 3rd floors AHUs looked clogged and the drip pan under the evaporators were clogged thereby allowing pool of water to collect around the area through which the final processed air passes into the building Inspection of the final air passage duct into the 4th and 3rd floors showed some stains on the panels inside the duct and the presence of many black spots. The stains on the ceiling tiles and water molecules/droplets seen on ventilation vents came from the pool of water in the area through which the final processed air passes before getting into the building. As the air passes through the evaporator, it picks up water molecules from chamber and transports it into ventilation duct system. While passing through the duct system, the water molecule drops out of the air and soaks the duct system and its insulting material. At saturation point, the insulation material starts dropping water onto the ceiling tiles. AHU 1 and 2 are served by a Refrigerating Trailer Unit-the installed refrigerating unit has stopped working. Operating Rooms AHU is being served by a Skid mounted refrigerating Unit. The installed roof top refrigerating unit is rotted and cannot be repaired. AHUs serving the 3rd and 4th floors need thorough cleaning and refurbishment. The refrigerating compressor serving units need refurbishment. The existing refrigerating units in the central processing room (CUPS) have a lot of degraded mechanical components. Building automation system (BAS) barely functioning and inadequate preventative maintenance serving the HVAC systems. A trailer and skid mounted HVAC temporary systems have been in use for more than one year. References: 42 CFR §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. NFPA 101, 2012 edition: 19.1.1.1.3? General. The provisions of Chapter 4, General, shall apply. NFPA 101, 2012 edition: 4.6.1.2? Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction. NFPA 101, 2012 edition: 4.6.1.3? Where it is evident that a reasonable degree of safety is provided, any requirement shall be permitted to be modified if, in the judgment of the authority having jurisdiction, its application would be hazardous under normal occupancy conditions. NFPA 101, 2012 edition: 9.2.1? Air-Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air-conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless such installations are approved existing installations, which shall be permitted to be continued in service. NFPA 101, 2012 edition: 19.5.2.1? Heating, ventilating, and air-conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer’s specifications, unless otherwise modified by 18.5.2.2. NFPA 101, 2012 edition: 2.1 The documents referenced in this chapter, or portions of such documents, are referenced within this Code, shall be considered part of the requirements of this Code, and the following shall also apply: (1)*Documents referenced in this chapter, or portion of such documents, shall only be applicable to the extent called for within other chapters of this Code. (2)?Where the requirements of a referenced code or standard differ from the requirements of this Code, the requirements of this Code shall govern. (3)*Existing buildings or installations that do not comply with the provisions of the codes or standards referenced in this chapter shall be permitted to be continued in service, provided that the lack of conformity with these documents does not present a serious hazard to the occupants as determined by the authority having jurisdiction. C.1.2.4? ASHRAE Publications. American Society of Heating, Refrigerating and Air Conditioning Engineers, Inc., 1791 Tullie Circle, NE, Atlanta, GA 30329-2305. www.ashrae.org ANSI/ASHARE/ASHE Standard 170; 4.1.2.2.1 Heating, Ventilation, and Air-Conditioning System Alterations. Alterations to mechanical systems serving the building heating, cooling, or ventilating needs shall comply with the requirements of Section 6, “Systems and Equipment,” applicable to those specific portions of the building and its systems that are being altered. Any new mechanical equipment installed in conjunction with the alteration as a direct replacement of existing mechanical equipment shall comply with the provisions of Sections 6.2, 6.4, 6.5, and 6.6. ANSI/ASHARE/ASHE Standard 170; 6. Air-handling and distribution systems are required to provide health care facilities not only with a comfortable environment but also with ventilation to dilute and remove contaminants, to provide conditioned air, and to assist in controlling the transmission of airborne infection. In order to meet these requirements, air-handling and distribution systems shall be designed according to the requirements of this standard. ANSI/ASHARE/ASHE Standard 170; 8.5 Documentation of New or Remodeled HVAC Systems. Owners shall retain an acceptance testing report for their files. In addition, the design shall include requirements for operations and maintenance staff training that is sufficient for the staff to keep all HVAC equipment in a condition that will maintain the original design intent for ventilation. Training of operating staff shall include an explanation of the design intent. The training materials shall include, at a minimum, the following: a. O&M procedures b. Temperature and pressure control operation in all modes c. Acceptable tolerances for system temperatures and pressures d. Procedures for operations under emergency power or other abnormal conditions that have been considered in the facility design.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 10135 Based on interview and record review, the facility failed to thoroughly and timely investigate an incident of potential neglect involving 1 of 21 patients discharged from their emergency department (ED) (Patient #1). Patient #1 was discharged from the ED on 01/26/2026 and found deceased in front of a convenience store in a wheelchair on 01/27/2026. Patient #1 had on a hospital armband and gown when found. This deficient practice had the likelihood to affect all patients being discharged from the hospital. Findings include: Review of Patient #1’s record revealed he was a 61-year-old male who presented to the Emergency department (ED) on 01/25/2026 at 6:59 p.m. via ambulance. Patient #1 was brought in for medical clearance so the Port Arthur police department could take him to a warming station. Patient #1 was triaged at 7:05 p.m. and was given an emergency severity index of 4 and his vital signs were 36.8 degrees Celsius, 79 pulse, 16 respirations, blood pressure of 159/74, oxygen saturation of 99 percent on room air and had no pain. At 7:13 p.m. Patient #1 was medically screened. According to the physician’s assessment the patient had excoriation and skin irritation in different parts of the body due to sitting in his own feces and urine. Patient #1 had lymphedema noted and venous stasis in both extremities. The following documentation was in the chart: “The patient was subsequently discharged to home with a plan to be followed up by his/her PCP within the next 1-2 weeks..” According to nurses notes dated 01/25/2026 at 11:56 p.m., there was documentation that due to the inability to arrange transport, the patient was placed in the ED lobby and provided with additional warm blankets. The patient was provided with snacks and beverages. He was also informed that he could rest in the ED lobby due to the weather circumstances. There was discharge plan dated 01/26/2026 on record, but there was no way to tell what time the physician’s order to discharge was written. Review of the police report incident #202600003601 revealed an occurrence date of 01/27/2026 at 9:13 a.m. Documentation on the report revealed that the incident occurred at the Super Stop #1 on 9th avenue. According to the report “OFFICER RESPONDED TO 8196 9TH AVE, IN REFERENCE TO AN UNATTENDED DEATH.” Review of a Port Arthur newspaper article dated 01/28/2026 at 2:38 p.m. revealed the following: “Port Arthur police are investigating the death of a man found Tuesday morning in a wheelchair, wearing a hospital gown and wristband, behind a store in freezing temperatures.” During interviews the following was stated: On 02/03/2026, after 1:26 p.m., Staff #6 was asked if there were any incident involving the emergency department and she replied, “not directly.” Staff #6 said Patient #1 had been a patient in the ED the day before the post on social media. Patient #1 was here during the cold weather. Port Arthur Police Department (PAPD) called City EMS here to be cleaned up and medically checked out. City EMS said that the police patient was cleared and cleaned up, and that PAPD would pick up Patient #1 and take him to the warming shelter. When PAPD was called, they stated that they could not pick him up. Staff began calling the warming centers, but the warming center stated they could not take him because he was wheelchair-bound. Patient #1 was showered and dressed in clean clothes. He also received an MSE and was cleared medically. Patient #1 was in the ED for around 6 hours, and then he was discharged and allowed to stay in the Lobby. Patient #1 had his belongings bag, his jacket on, and the staff supplied him with multiple warm blankets. He was allowed to stay in our lobby until the next morning. Our social worker came in and spoke with Patient #1 that morning around 8:00 a.m. to help him with placement at a nursing home. After 8:00 a.m., Patient #1 wanted to leave when the transit bus got to the hospital. Staff #6 said that she had been spoken to about the incident after the Facebook post, but not in a formal manner. On 02/03/2026 at 2:24 p.m., Staff#2, said Patient #1 was admitted to our ED department on 1/25/2026 and discharged early morning on 1/26/2025. Patient #1 was a homeless man whom they had seen multiple times for electrolyte imbalance. He was sent here to the ED on 1/25/2026 by the PAPD because the police were trying to get him to a warming station, but the warming station staff would not take Patient #1 because he was soiled in urine and feces. Patient #1 was showered by the ED staff and dressed in clean clothes. He received a medical screening and was medically cleared. He was then discharged and allowed to stay in the ED lobby. Social Services saw Patient #1 on the morning of 1/26/2025 to try to help place him in a nursing home or at the warming station. Patient #1 did not want to go to the nursing home because he didn’t want to give up the check he received monthly, and he didn’t want to go to the warming station because they won’t let him drink alcohol while he is there. He had a bus pass and just wanted to wait for the transit bus in the ED lobby. Staff #2 said she first saw the post on social media on 1/28/2026. She said she was unsure if the man was our patient because she didn’t know the name of the man found dead. Staff #2 said she assumed he was probably one of their patients because they were the only hospital here in the area. Staff #2 said she then started inquiring about what happened, and was this one of our patients. She spoke with the ED director and case management. She found out that the patient was Patient #1 and that multiple options had been given to him for places to go. Patient #1 was offered priority transport to go to the warming station, and Patient #1 refused. Patient #1 was also given the option to just stay in the ED lobby, but he refused that also. Patient #1 chose to get on the city bus. Staff #2 said she spoke with the ED manager and found out that Patient #1 did not meet the criteria to be admitted to the hospital. Staff #2 said she did not do any documentation of her investigation because Patient #1 was discharged from their hospital when the incident occurred. My investigation findings were taken to the CEO and to Corporate. They believed that since the patient was already discharged, it was not considered a complaint, grievance, or incident. Staff #2 said the police department had not talked to her yet about the incident. On 02/03/2025 at 2:39 p.m., Staff #3 said Patient #1 came to the ED by PAPD. The warming shelter would not accept him because he was soiled. ED staff bathed and cleaned him up, and once he was discharged, he was allowed to stay in the ED lobby. The next morning, when the social worker came in, she offered Patient #1 several options, but Patient #1 declined all of them. No formal investigation was done into this incident. If a formal complaint, grievance, or incident had been reported, then we would do a deep dive into Patient #1’s medical record and a full investigation to ensure our policy was followed. She stated that since he wasn’t a patient at this time and incident report would not have been done. On 02/04/2026 at 8:52 a.m., Staff #12, said she did not know Patient #1 personally, but he spoke to her as she was coming into the ED for her shift around 6:40 a.m. Patient #1 was in a wheelchair, covered with his jacket and some blankets; he also had his belongings bag. Staff #12 said she noticed that he had urinated on himself, so she asked what they were doing with Patient #1. She also notified the ED technicians that Patient #1 had soiled himself. A message for case management had been left for them to come and see him. Staff #16, who was the nurse in the ED admissions process, texted or called case management or the social worker. The social worker said that the Patient #1 refused previous nursing home placement. Staff #12 said she saw Staff #16 and Staff #13 go and speak with Patient #1. Staff #16 later came to her to help her hold Patient #1’s legs so she could move him to the ED entrance and park him just inside the doors to stay warm until the bus arrived. By the time she asked her, Patient #1 had already wheeled himself out the door and was headed for the bus stop. Staff #12 said she heard Patient #1 had been helped on the bus by Staff #14. When she returned on Tuesday, it was all over Facebook. Staff #12 said she had never been interviewed by administrative staff about Patient #1. On 02/04/2026 at 9:14 a.m., Staff #13, said she was familiar with Patient #1, and he had come to their ED multiple times. He had fallen many times and had come into the ED. He was homeless and an alcoholic. PAPD brought him to the ED multiple times. On several occasions, we have tried to get him into a nursing home. He had left against medical advice (AMA) from our ED many times. Patient #1 refuses any placement we can get for him. Staff #13 said she arrived on 1/26/2026 between 6:30 and 7:00 a.m. Patient #1 wasn’t on the tracker the morning she arrived, so he wasn’t an active patient at that time. My triage nurse, Staff #16, let me know that he was in the lobby and was unsure what they could do for him. Staff #13 said she went and asked Patient #1 what his plan was. He said he was waiting for it to get a little lighter outside, and he planned to catch the bus. Staff #13 said she told Patient #1 that it was really cold outside and that they could help get him into the nursing home. Patient #1 stated he wasn’t going to the nursing home; he wanted to get on the bus. Staff #16 and Staff #8 were both present during her conversation with him. No one ever told her that they helped Patient #1 out to the bus stop. Staff #13 said she had not been interviewed by administrative staff about Patient #1. Staff #13 said she worked the day after, which was Tuesday, and she found out from EMS workers that Patient #1 had passed away. On 02/04/2026 at 9:30 a.m., Staff #14 said she saw Patient #1 in the front ED lobby when she arrived at work. She wasn’t sure what was going on with him. She had stepped out of the ambulance bay doors to take a phone call and saw Patient #1 at the bus stop. Staff #14 watched Patient #1 get on the bus with help from the lady who was driving the bus. The bus has a chair lift. No one had ever talked to her about Patient #1 until yesterday, 02/03/2026. On 02/04/2026 at 10:21 a.m., Staff #18 said she went to talk to Patient #1 around 8:00 a.m. that morning. She had Patient #1 placed in Cascade Nursing Home previously in October of 2025 when he was an inpatient. He went to Cascade Nursing Home and left once he found out he would have to give up his check. They stated that they would not take him back. She also got him set up to go to Harmony Nursing Home in December 2025, but Patient #1 refused to go to Harmony Nursing Home because he didn’t want to give up his check. Harmony stated that if he changed his mind, they would take him. Staff #18 said she never contacted Harmony Nursing Home on 1/26/2026 because Patient #1 continued to say he wasn’t giving up his check. Staff #18 said she did not call the police or arrange for medical transport because Patient #1 continued to state he wanted to take the bus. Staff #18 said she did not document anything the day she spoke with Patient #1. Staff #18 said she documented a handwritten note and scanned it into Patient #1’s medical record the day after she saw the post on Facebook. Staff #18 said she did not notify administration about seeing the post on Facebook because she was off that day. Review of a facility’s policy named “ Incident Reports: General Overview Department/Chapter: Rights and Responsibilities” dated 01/31/2024 revealed the following: “Policy Any event which is not consistent with the desired care of apatient or the customary operations of the hospital, regardless of whether harm has occurred, should be reported as soon as possible to the immediate supervisor and to the Risk Manager (at a minimum). Department of Quality and Safety (Q/S) ensures timely investigation and corrective action plans, as well as timely reporting to regulating and accrediting agencies, and to patient and/or family..” “ ...Incident: An undesirable and unexpected event, which has an actual, potential or perceived adverse impact on a patient or visitor (Requires Investigation and May Require Corrective Action.) ... ...Serious Incidents: 1.Sentinel Event: For hospitals accredited by the Joint Commission is a subset of Reportable Event that is a patient safety event(not primarily related to the natural course of the patient’s illness or underlying condition) that reaches the patient and results in any of the following: *Death; ... *Death caused by self-inflicted injurious behavior if any of the following apply: ...Within 7 days of discharge from emergency department (ED) ...””

“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: 10135 Based on observation, interview and record review, the facility failed to ensure timely repairs on patient care equipment on 4 of 4 units that were reviewed for equipment concerns (operating room, intensive care unit, medical-surgical unit, and radiology). This deficient practice had the likelihood to cause harm to all patients. Findings include: Review of the facility’s work order list revealed the following request for repairs: Operating room/Intensive care unit On 01/30/2025 there were 3 light switches not working in the operating room. The order was classified as a priority 2 meaning urgent. On 01/31/2025 the anteroom sink in CV7 was not working in the intensive care unit. The order was classified as a priority 2 meaning urgent. On 03/25/2025 a Hill rom bariatric compella bed was not inflating in the intensive care unit. The order was classified as a priority 3 meaning important. During an interview on 05/06/2025 at 5:00 p.m., Staff #2 said they had just checked the lights in the operating room. Two lights were working and three were not working. The sink in the anteroom was not working and the whole sink needed to be replaced. They would call the manufacturer about the beds because plant operations and Biomed department did not work on them. Radiology According to an email and “PHILLIPS SERVICE LOG” dated 03/19/2025 there was documentation that the screen on a portable x-ray kept freezing and locking up. During an interview on 05/06/2025 at 1:26 p.m., Staff #19 revealed that a portable x-ray machine needed fixing and that he had put the order in on 03/19/2025. Staff #19 showed the surveyor the equipment and demonstrated how the cable was loose on the equipment. Medical-Surgical unit According to the facility’s work order list revealed there was an order written 04/14/2025 that the medication room door was not locking on the Medical-Surgical unit. During an observation on 05/06/2025 at 2:11 p.m. the medication room door was still not locking. There was one patient medication bin in the room which had medication stored in it. Staff #2 confirmed the observations. Review of a facility’s policy named “Equipment Repair and Problem Identification Department /Chapter:EOC/Medical Equipment” approved 07/25/2023 revealed the following: “A. When requesting repair or maintenance of patient care equipment, staff from the user department will complete a maintenance request and send it to the Engineering/Biomedical Department. B. The Biomedical technician will respond as follows: Priority 1- Immediate threat to safety-immediate response. Priority 2- Will cause delay of patient care-immediate response. Priority 3- Not impacting the ability to provide care-as soon as possible given other tasks of higher priority...””

“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: 10135 Based on observation, interview and record review, the facility failed to ensure the environment and patient equipment was kept sanitary in 3 of 6 departments/ units that were observed (Intensive care unit (ICU), Emergency department (ED) and Telemetry). The facility failed to: A. ensure mattresses were kept in a condition where they could be sanitized. B. ensure patient equipment was kept sanitary and supplies were stored in a manner, to prevent cross contamination. This deficient practice had the likelihood to cause harm to all patients. Findings include: During observations on 05/05/2025 after 2:47 p.m. the following was found: MICU (Medical intensive care unit) Room #5 The covering on a mattress on a patient bed was ripped and the cushion inside the mattress was exposed. There was no way the mattress could be properly sanitized. Staff #’s 1 and 2 confirmed the observation. ICU Equipment storage room and clean utility room There were intravenous/feeding pumps stored in a room. The bases of the pumps were soiled with dried yellow and brown stains, had peeling paint, and rusted wheel castors. A raised toilet seat was stored in the room. Underneath the toilet seat there was an area that was rusted. There was no way the seat could be properly sanitized. Staff #2 identified the equipment in the room as being clean and confirmed the observations. ICU Equipment storage /Multipurpose room There was a sign on the door that read” CLEAN EQUIPMENT & FULL/PARTIAL O2 TANKS Do NOT place dirty equipment in this room. Please clean & return equipment to designated location.” There was a bair hugger in the room and the cord and hose to unit were on the floor. They were not wrapped on the unit in a manner to prevent them from getting soiled. There were clean toilet seats and used and unused tanks of oxygen stored in the room. Other supplies found in the room were bottles of antiseptic antimicrobial skin cleanser Hibiclens, sterile test tube trays, and sterile thoracentesis trays. Trays of assorted cables and wall mount suction regulators, vital sign equipment, transport wheelchairs and sequential compression pumps were also stored in the room. There was no separation of sterile and non-sterile supplies/equipment. Staff #’s 1 and 2 confirmed the observation. During observations on 05/06/2025 after 11:06 a.m. the following was found: ED bay #12 An infusion pump was in the room and ready for use. The base of the pole the infusion pump was attached to was rusted and had peeling paint. The wheels had hair wrapped around them. A metal linen cart in the room had wheel casters that were rusted. A cabinet door was opened and the floor of the cabinet was soiled with light brown particles. The inside of the cabinet door had a dark brown dried smeared substance on it. ED clean utility room Had infusion pumps, bair huggers, wall mount suction regulators, bags of patient dressing supplies, personal protective equipment, and patient toilet seat pails stored in the room. Toilet seats were stored in the room and the frames of the seats were rusted. There were also boxes of casting/splinting supplies, some were open and some were closed. The bottom drawer of the cart which contained more splinting and casting supplies was opened. The inside perimeter of the drawer had a buildup of spills, dust and a dead fly. A battery charger was stored on a shelf and it had an open compartment which was soiled with brown dried spills and rust. The charger was stored on an open shelf and stored up against boxes of face shields, mask and disposable stethoscopes. Underneath the battery charger was a shelf containers of sanitizing wipes. There was a locker in the room which contained bags of patient belongings that were brought into the ED. ED bay #7 Had fluid warmers, infusion pumps, and linen carts in the room that were ready for use. The bases of the pumps and carts had peeling paint and wheel casters that were rusted. When the mattress was lifted on the bed in the room, the bedframe was observed to be soiled with a dried brown substance and hair. The mattress covering had small holes and the inside cushion could be seen. The mattress could not be sanitized with the holes in it. Staff #2 confirmed the observations. Review of a facility’s policy named “Storage and Handling of Medical and Surgical Supplies Chapter:Infection Control Policy Number: 1C18 with a revision date of 08/15/2023 revealed the following: “ ...D. Storage of clean and sterile medical and surgical supplies 1.General Storage Guidelines a. Supplies will be stored in a manner that prevents package compromise and provides protection against dust, moisture, insects, and temperature and humidity extremes. This applies to storage in Materials Management Storeroom, designated bulk storage areas and inpatient care areas .... 47892 On an observation tour of the Telemetry floor on 5/6/2025 after 11:30 PM with Staff #1 and Staff #10. The following was revealed: Inpatient room 419 The protective covering on the inpatient bed mattress was torn on the underside where the mattress rests against the bed mechanics that raise and lower the head of the bed on the right and left side. There was also chipped paint exposing wood on the sofa bed. Clean and Sterile Supply Room Two eight-ounce bottles of betadine preparation solution were expired. The expiration date on both bottles was 04/2024. Clean Equipment Room The clean equipment room had multiple IV(intravenous medication) poles. All the IV pole bases had chipped paint and rust. An interview was conducted on 5/06/2025 after 11:30 PM with Staff #1 and #10. Staff #1 and #10 were asked if they agreed with these findings. Staff #1 and #10 confirmed these findings.”