Parkview Hospital

“COMPLIANCE FED, ST, AND LOCAL LAWS AND REGS CFR(s): The CAH is in compliance with applicable Federal laws and regulations related to the health and safety of patients. This Standard is not met as evidenced by: 31690 Based on interview and record review, it was determined that the facility failed to follow its own policy in regard to reporting animal bites. Findings were: Review of an undated Facility policy entitled “Animal Bites” stated in part ... “F. Reporting 1. Report animal bites to local/state public health authorities as required by law. 2. Notify animal control for follow-up and quarantine of domestic animals when applicable. VI. Responsibilities - Physicians/Providers: Perform assessment, wound care, prescribe prophylaxis, and complete required documentation. - Nursing Staff: Assist in wound care, patient education, and reporting. - Infection Control / Public Health Liaison: Ensure compliance with reporting requirements ...” On 2/28/25, patient # 7 was seen in the ED after being bitten by a rabbit. There is no documented evidence that the bite was reported to local/state public health authorities. Staff #3, CNO, verified these findings and reported that the nurse should have reported the incident.”

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 43999 Based on observation, policy review and interviews the hospital’s infection prevention and control program failed to maintain a clean and sanitary environment to avoid sources and transmission of infection. Findings : In an article published by Spectrum Health in July 2014 it was stated, “The heavier corrugated cardboard shipping boxes might harbor vermin or insects and spread the pests to areas where the boxes are stored after delivery. Corrugated cardboard boxes are not appropriate as storage units in medical or clean supply rooms. These boxes are not appropriate because they are an excellent harbor for insects and pests.” A review of the hospital’s “ Maintaining a Sanitary Environment Policy 6 Revised 10/2024 partly stated, ... POLICY: 1. Parkview Hospital shall provide and maintain a sanitary environment to avoid sources and transmission of infections and communicable diseases. 2. All areas of the hospital must be clean and sanitary. This includes all hospital units/departments and off-site locations. 3. Infection prevention and control policies and procedures for the maintenance of a sanitary physical environment are based on national guidelines and address the following: a. Ventilation and water quality control issues, including measures taken to maintain a safe environment during internal or external construction/renovation...” During a tour of the hospital on 9/15/25, accompanied by Chief Nursing Officer (CNO), Staff #1 the following was observed: Central Supply storage area outside the hospital had shelves with cardboard shipping boxes stored above containers that held opened clean supplies. Other shelves held shipping boxes adjacent to opened clean supplies, there was no differentiation between clean supplies and shipping boxes. Shipping boxes of intravenous (IV) fluids were observed being stored on the floor in the supply area. Corrugated boxes are not appropriate because they are an excellent harbor for insects and pests. In the patient/staff nutrition room on the hospital floor, the ice machine’s drain was plumbed under the only sink in the room with wet particle board and brownish black substance observed with a container and other supplies stored . The laboratory staff restroom had damaged sheetrock on the left side and at the back of the toilet . Staff #1 acknowledged the above findings during the tour of the facility 9/15/25.”

“A life safety code LSC survey was conducted on site on 08/27/2025. An entrance conference was held for the hospital ’ s interim CEO in the afternoon of 08/27/2025 to discuss the purpose of the LSC survey, and the survey process was explained. Instructions were provided on writing plans of correction. 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. An LSC exit conference was conducted on 08/27/2025 in the hospital. In attendance was the interim CEO. 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.”

“Protection - Other CFR(s): NFPA 101 Protection - Other List in the REMARKS section any LSC Section 18.3 and 19.3 Protection requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 30174 Based on observations made during the survey of the facility while accompanied by the hospital’s interim CEO it was observed that the MAIN ELECTRICAL ROOM WAS MISSING THE REQUIRED 1 HOUR FIRE RATED WALLS - There were no 1 hour fire-rated walls separating the MAIN ELECTRICAL ROOM (Normal Power) from the remainder of the Hospital Facility. HLR-2007: 133.162 (d)(5)(D) “Services and switchboards. Electrical service and switchboards serving the required hospital components shall be installed above the designated 100 - year flood plain. Main switchboards shall be located in separate rooms, separated from adjacent areas with one-hour fire rated enclosures containing only electrical switchgear and distribution panels and shall be accessible to authorized persons only. These rooms shall be ventilated to provide an environment free of corrosive or explosive fumes and gases, or any flammable and combustible materials. Switchboards shall be located convenient for use and readily accessible for maintenance as required by NFPA 70, Article 384. Overload protective devices shall operate properly in ambient temperatures.” NFPA 101, 2012: 8.3.4.1 “Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other.” NFPA 101, 2003: 8.3.4.1 “Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other.””

“Health Care Facilities Code - Other CFR(s): NFPA 101 Health Care Facilities Code - Other List in the REMARKS section any NFPA 99 requirements (excluding Chapter 7, 8, 12, and 13) that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Health Care Facilities Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 30174 ISSUE 1: Based on observations made during the survey of the facility while accompanied by the hospital’s interim CEO it was observed that the required “GEN SET” for the EMERGENCY GENERATOR was missing. The “GEN SET” components shall be powered by the Life Safety Branch of the EES. The missing components of the “GEN SET” are as follows: 1a. LIGHT with charging component must have 90-minute battery back-up capability. 1b. RED RECEPTACLE. NFPA 99, 2012: 6.4.2.2.3.2. The life safety branch shall supply power for the lighting, receptacles, and equipment as follows: (4) Generator Set Location as follows: (a) Task illumination (b) Battery charger for emergency battery-powered lighting unit(s) (c) Select receptacles at the generator set location and essential electrical system transfer switch locations ISSUE 2: Based on observations made during the survey of the facility while accompanied by the hospital’s interim CEO it was observed that an electrical opening (receptacle) in the MED GAS STORAGE ROOM was located less than 60” A.F.F. This does not comply with the following: NFPA 99, 2002: 5.1.3.3.2(5) “Locations for central supply systems and the storage of medical gases shall be compliant with NFPA 70 National Electric Code, for ordinary locations, with electrical devices located at or above 1520mm (5 ft) above finished floor to avoid physical damage.””