Porter Hospital Inc.

“INFECTION PREVENT & CONTROL & ABT STEWAR PROG CFR(s): The CAH must have active facility-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 coordination with the facility-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 12112 Based on observations, interviews and record/policy review, the Condition of Participation 485.640: Infection Prevention and Antibiotic Stewardship Program was not met as evidenced by the CAHs failure to employ methods for preventing and controlling the transmission of infections in the perioperative suite, radiology suite, and on the medical/surgical unit. Findings include: Refer to Tag C-1206”

“CONSTRUCTION CFR(s): The CAH is constructed, arranged, and maintained to ensure access to and safety of patients, and provides adequate space for the provision of services. This Standard is not met as evidenced by: 12112 Based on observation and interview, the CAH failed to ensure the Emergency Department’s environment maintained patient safety, as evidenced by failing to secure a soiled utility room containing housekeeping chemicals. There was also a failure to properly maintain the environment in the Clean Reprocessing located within the Surgical Unit. Findings include: 1. During a tour of the Surgical Unit (specialized hospital department designed for conducting surgical procedures and providing perioperative care), accompanied by two Nurse Managers (NM) and an Accreditation staff member on 5/4/26 at 11:30 AM, an observation was made in the Clean Reprocessing area (utilized for the sterilization and disinfection of surgical instruments), noting a breach in the wall that extended over six inches at the base of the wall above the kickplate, where a cart holding surgical items was awaiting sterilization. A broken surface/crevice reduces the integrity of the environmental surface, allowing dirt and particles to enter the breach. Per interview on 5/4/26 at approximately 1:00 PM, the NM for the Clean Processing area confirmed the breach in the wall and the need to repair it. 2. During a tour of the Emergency Department (ED) on 5/4/26 at 3:30 PM with the Assistant Nurse Manager (ANM) and the Accreditation staff member, a soiled utility room located in one of the ED hallways, was observed to be unsecured and easily accessible to unauthorized individuals. The hallway was a high-traffic area where patients, visitors, and staff moved about in the ED. The room contained a hopper (“Flushing-rim clinical sink with a bedpan-rinsing device used for disposal of liquid clinical waste) with a brown/gray ring at the water line, cleaning wipes (CaviWipes, both bleach and hydrogen peroxide, two bottles of cleaning liquid (CaviCide), and two bottles of isopropyl alcohol. No separation was noted between clean supplies and soiled items. Per interview on 5/4/26 at 3:30 PM, the ANM confirmed that the soiled utility room door is unlocked and that the room’s contents are accessible to anyone attempting to gain entry. 3. At 4:22 PM on 5/4/26, an uncapped bottle of 0.5% proparacaine hydrochloride ophthalmic solution (a fast-acting topical anesthetic) was observed on top of an airway cart in the trauma bay. Both the Nurse Manager and the ANM confirmed the bottle should have been discarded after the patient was discharged.”

“PREMISES ARE CLEAN AND ORDERLY CFR(s): (4) The premises are clean and orderly; and This Standard is not met as evidenced by: 12112 Based on observation and interview, the CAH failed to maintain sufficient space for the provision of care and services in the Emergency Department (ED), including the use of recliner chairs and stretchers, limiting hallway clearance, and failing to maintain a safe egress. Findings include: During a tour of the ED on 5/6/26 at 2:00 PM with the Maintenance Tech, ANM, and an Accreditation staff member, it was confirmed that egress was impeded by items stored on both sides of the hallway, encroaching on the space needed to move patients and equipment freely. The hallway had 2 patients assigned, one on a stretcher one in a recliner. On the opposite side of the hallway was a large linen cart and patient equipment. The egress space between the patients and the equipment was limited. Privacy was difficult to maintain, especially with staff/visitors passing by the hallway where patients were assigned either a recliner or stretcher. In addition, the patient assigned to a recliner was not provided with a call-bell, creating a safety factor due to the patient’s inability to contact ED staff if necessary. In addition, the 2 patients observed in the hallway awaiting care, were without a patient location identifier, to ensure identity and patient safety. A third patient was observed in another side hallway who also lacked a patient location identifier. Review of facility policy titled “Maintaining Means of Egress”, last reviewed 05/2026, states “The corridor width is not obstructed by wall projections ...They must be no more than 36 inches wide and cannot project more than 6 inches into the corridor.” Maintenance Tech confirmed on 5/6/26 at 2:00 PM that the hallway didn’t comply with the facility policy.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (vi) Procedures that ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices. All patient diets, including therapeutic diets, must be ordered by the practitioner responsible for the care of the patients or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff in accordance with State law governing dietitians and nutrition professionals and that the requirement of § 483.25(i) of this chapter is met with respect to inpatients receiving post CAH SNF care. This Standard is not met as evidenced by: 29776 Based upon interview and record review, the Critical Access Hospital (CAH) failed to review and revise food and nutrition service policies and standard menus to ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices that align with the 2025-2030 U.S. Department of Agriculture (USDA) Dietary Guidelines for Americans. Findings include: An interview was conducted with the CAHs Registered Dietician [RD] on 5/5/26 at 12:28 PM. The RD stated the CAHs dietary policies are based upon the Nutrition Care Manual [NCM]. [NCM is professional practice resource for registered dietitian nutritionists.] (https://www.nutritioncaremanual.org)]. Per review of the NCM and confirmed by the RD, the NCM’s guidance references U.S. Department of Agriculture (USDA) guidelines dated 2020. Per review of the U.S. Department of Agriculture (USDA) website: Dietary Guidelines for Americans (https://cdn.realfood.gov/DGA.pdf), current guidelines are dated 2025-2030. Per interview with the Registered Dietician [RD], the RD confirmed the CAHs policies and menus were based on outdated USDA policies dated 2020, and not the most recent USDA policies dated 2025-2030.”

“PROTECTION OF RECORD INFORMATION CFR(s): The CAH maintains the confidentially of record information and provides safeguards against loss, destruction, or unauthorized use. This Standard is not met as evidenced by: 29776 Based on observation and staff interview the Critical Access Hospital (CAH) failed to store medical records in a manner that safeguarded against loss, destruction, and unauthorized use at one location (Clinic A). Findings include: During a tour of primary care Clinic A on 5/6/26 at 8:30 AM, accompanied by the Practice Manager, paper medical records were observed to be stored in the basement on 4 open multi-level shelving units underneath piping with sprinkler heads. These records were uncovered and there was a potential for water damage from the sprinkler system and/or damage from fire. The Practice Manager confirmed at the time of observation on 5/6/26 at 8:30 AM the records were not stored in a protected manner to assure they sustained no damage from water or fire.”

“INFECTION PREVENT & CONTROL POLICIES CFR(s): The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings; This Standard is not met as evidenced by: 12112 Based on observation, interview and record/policy review, the CAH failed to employ methods for preventing and controlling the transmission of infections in the perioperative suite, radiology suite, and on the medical/surgical unit. Findings include: 1a.) Per observation on 5/4/26 at 11:42 AM, of the perioperative procedure room, an opened package containing a Yank Auer (type) suction tip was noted to be attached to the suction set/up and canister. There was no indication when this package/set up was opened and/or how long it had been in the room. Upon further observation, unpackaged oxygen tubing was found wound around an oxygen wall outlet with no indication when the tubing was opened and/or how long it had been in the room. During an interview at that time, with Anesthesiologist #1, S/he stated that the tubing was reused throughout the day and was wiped down in between patients with “CaviWipes” (disinfectant). The oxygen was used for “blow by” and was placed on a patient’s chest during the procedure that was occurring. The tubing was typically changed two to three times a week. Per review of the “CONMED” instructions for use it states, “Suction Instruments, Sterile, Single-Use ...Yankauer Suction Instruments: Cautions: The ability to effectively clean and re-sterilize this single use device has not been established and subsequent re-use may adversely affect the performance, safety and/or sterility of the device.” Per review of the “Medline 7 Crush Resistant Oxygen Tubing” instructions for use it states, “Single patient use. Rx (prescription) only”. Per review of the policy, “Guidelines for Hand Hygiene and Standard Precautions” last revised 6/24, it states, “V. Patient Care Equipment ...d. Single-use items should be discarded following use.” b.) Per observation on 5/4/26 at 12:02 PM of Operating Room (OR) 2, an open package containing a Yank Auer suction tip was noted to be attached to the suction set/up canister without any indication how long it had been opened and/or in the room. On top of the Anesthesia Cart, there was an open package, containing an endotracheal tube (ET) (breathing tube) and an opened package containing a laryngoscope (scope used to view the throat). For both items there was no indication how long they had been opened and/or in the room. During an interview at 12:20 PM with Anesthesiologist #2, S/he stated that the ET balloon was checked daily and that anywhere S/he had worked it was common practice to have intubation supplies “at the ready”. During an observation at 12:19 PM, tape residue was noted on the top back portion of the anesthesia machine and dust particles were noted on the top of the cart which Anesthesiologist #2 also confirmed. Per review of 2008 “Medline Endotracheal Tubes” directions for use it states, “Intubation (putting in a breathing tube) and extubation (taking out a breathing tube) should be performed by adhering to current medical standards, techniques and practices.” Per review of the “McGrath MAC instructions for use received on 5/6/26, it states, “Warnings ...Blades cannot be adequately cleaned and/or sterilized by the user in order to facilitate safe reuse, and are therefore intended for single use.” c.) Per observation on 5/4/26 at approximately 12:30 PM of the sub-sterile room, paper signage was noted to be taped on the autoclave and flash sterilizer. The Nurse Manager confirmed at the time that this paper could not be cleaned and removed the signage. There was also a wooden silhouette in which a lead apron was draped over that could not be effectively cleaned which was also confirmed by the Nurse Manager. Per observation on 5/4/26 at approximately 12:45 PM of the perioperative hallway, composite clip boards were noted to be on the code cart and malignant hyperthermia cart; in the “warehouse” (clean storage area of instruments and supplies) paper signage was noted throughout the shelving; and in the central supply clean/dirty areas, wood composite clip boards were also noted. During an interview at that time with the Nurse Manager, S/he confirmed that these items could not be effectively cleaned and should be removed. Per review of the policy, “Guidelines for Hand Hygiene and Standard Precautions” last revised 6/24, it states, “i. Standard Precautions-designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in hospitals ...a. Standard Precautions is a combination of work practices, engineering controls and personal protective equipment ...V. Patient Care Equipment ...a. Follow established policies and procedures for containing, transporting, and handling patient care equipment and instruments ... b. Follow established policies and procedures for routine and targeted cleaning of environmental surfaces and equipment as indicated by the level of patient contact and degree of soiling.” d.) Per observation on 5/4/26 at 12:56 PM, of the Post Anesthesia Care Unit (PACU), the code carts contained wood composite clip boards, and in bay #3 of the PACU an opened Yank Auer tip was noted to be attached to the suction set/up canister without any indication how long it had been opened and/or in the room. The Nurse Manager stated that S/he did not know how long the supplies were there. Throughout the perioperative suite, where oxygen and vacuum gas wall mounts were present there were green and yellow trees that were attached to these without any processes for removing and/or cleaning. Per interview with the Nurse Manager at that time, S/he did not know whether these supplies were single use and/or multiuse. Per review of the “AirLife” instructions for use received on 5/6/26, it states, “Universal Oxygen Nut and Nipple Connection ...For Single Patient Use”. Per review of the policy, “Perioperative Infection Prevention “last revised on 6/24, it states, “X Ambulatory Surgery (ASU)/Post-Anesthesia Care Unit (PACU) a. Materials and Equipment ...v. equipment shall be either discarded if disposable, or appropriately cleaned and sterilized, if not disposable.” e.) Per observation on 5/5/26 at 12:20 PM of the room turnover for OR#2 there were multiple observations of staff members coming and going in and out of OR#2 with gloves on. There was no way to know if the gloves were clean and/or contaminated. There were also several observations of staff members removing gloves and putting on clean gloves without performing hand hygiene. Per interview at 12:28 PM with the Nurse Manager, S/he stated that it depended on what the staff were doing whether they needed to remove their gloves prior to leaving the OR. If a staff member was removing garbage and/or soiled linen, the expectation would be to remove the gloves after the handling of these items, perform hand hygiene and then put on clean gloves. S/He further confirmed that hand hygiene should be performed prior to putting gloves on and any time gloves were removed prior to putting on new ones. Per review of the policy, “Guidelines for Hand Hygiene and Standard Precautions” last revised 6/24, it states, “I. Hand Hygiene ...a. General ...i. Careful hand hygiene, which includes the use of alcohol hand sanitizer or soap and water hand washing with an antimicrobial soap, remains one of the most important measures for preventing the spread of pathogens in healthcare settings and reduces the risk of healthcare-associated infection ...II Use of Personal Protective Equipment (PPE) ...b. Gloves ...v. Remove gloves after contact with a patient and/or the surrounding environment (incl. medical equipment) ...x. When gloves are removed, appropriate hand hygiene should be performed immediately to avoid transfer of microorganisms to other patients or the environment.” f.) Per observation at 12:42 PM on 5/5/26 of the designated dirty area of central sterile processing, instruments from a hysterectomy case from the morning were noted to be on a table with dried blood and other debris. Per interview at approximately 1:00 PM with the central sterile tech, S/he stated that S/he received instruments with foam, in solution, and dry noting that S/he did not receive instruments in a consistent way. Per observation on 5/5/26 at 1:17 PM of the designated clean area of central sterile processing, a surgical tech put an endoscope in a high-level disinfectant machine to start the cleaning. The tech proceeded with the same gloves to remove a second scope that had finished the high-level disinfectant cleaning process and proceeded to flush the scope with alcohol and air, with the same gloves, obtained a pen, gathered the scope’s record of receipt of cleaning, put the scope in a pink bin and transported the scope to the holding cabinet. Per interview at approximately 2:00 PM with the Nurse Manager, S/he confirmed that the tech should have changed gloves, performed hand hygiene, and donned new gloves prior to taking the second scope out of the high-level disinfectant machine as well as at any point where their gloves would have been contaminated. The Nurse Manager further confirmed that instruments post-surgery were to be foamed, put in a solution and/or covered with a damp cloth/towel. Per review of the policy, “Perioperative Infection Prevention” last revised on 6/24, it states, “VIII Instrument Decontamination a. All soiled instruments are processed in Central Sterile Processing (CSS) as follows: i. sprayed with enzymatic cleaner upon arrival in decontamination room. ii. Soaked in enzyme bath then rinsed off by hand wearing gloves, apron, eye protection”. Per interview on 5/6/26 at 2:03 PM with the CAHs Infection Preventionist, S/he confirmed that hand hygiene should be performed prior to glove use and after glove removal. S/He also confirmed that patient care supplies should not be opened prior to use. 2. Per observation on 5/5/26 at 9:35 AM of X-ray room #1 in the radiology suite, a positioning wedge was located on the counter. The wedge was noted to have cracks in the integrity of the material on the edges and on one side the material was breached with a cut approximately an inch wide. Per interview at 9:38 AM with the Director of Radiology, S/he confirmed that the wedge was not in good condition and could not be effectively cleaned. Per review of the policy, “Guidelines for Hand Hygiene and Standard Precautions” last revised 6/24, it states, “VI. Environmental Control ...a. Environmental surfaces, beds, bedrails, bedside equipment, and other frequently touched surfaces must be adequately cleaned and disinfected ...b. Follow established policies and procedures for routine and targeted cleaning of environmental surfaces and equipment as indicated by the level of patient contact and degree of soiling.” 3. On 5/4/2026 at approximately 12:50 PM during a tour of the Med/Surg Nurses station, an observation was made of five glucometers (machine used to measure blood glucose) sitting in charging bases. They were labeled with a tape-like substance in two places on each of the five glucometers. Per interview with the interim Nurse Manager, S/he stated that the labels were in place for glucometer identification should the glucometer malfunction and need repair. S/he confirmed that the tape-like substance could not be properly disinfected between patient use.””