Montgomery General Hospital

“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: 40165 Based on observation, record review and staff interview the facility failed to keep all essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition. Findings Include: a) Observation on 1/7/25 revealed an appliance cord that served a kitchen refrigerator, spliced, with exposed wire connectors, to make the chord longer to reach a receptacle. b) During record review on 1/08/25, findings revealed there was several failed damper tests with no corrective action for the following dampers: i. ID- 08696 ii. ID- 08686 c) An observation on 1/7/25 at approximately 1:45 p.m.., revealed a sprinkler heads (3) in the Kitchen, near the dish area, that were corroded. d)An observation on 1/7/25 at approximately 11:38 a.m., revealed a hood extinguishing system without proper extinguishing coverage over the griddle. e)Record review on 1/8/25 at approximately 9:00 a.m. revealed the facility failed to ensure that the fire rated doors in Hospital were inspected annually. f)Record review on 1/8/25 at approximately 10:35 a.m.., revealed no current documentation for testing of the physical integrity, correct polarity, continuity of the grounding circuit, or retention force for each electrical receptacle at the patient bed locations in the facility. g) These findings were verified during an exit interview with the Maintenance Director,and CEO on 1/09/25 at 11:30 a.m.”

“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: 42792 Based on observation, document review, and staff interview, the facility failed to ensure that all food items were properly stored after the package was opened and all food items were properly dated when opened for patient consumption. This failure has the potential to adversely affect all patient receiving meals at the facility. Findings are as follows: An observation was conducted on 01/07/25 at 3:20 p.m. of the kitchen area, accompanied by Employee #2 and Employee #3. In the kitchen area near a six (6) burner stove had a counter space connected to the stove surface. Directly above the counter space there was a shelf that had five (5) packages of assorted types of bread and buns, that included, but not limited to: two (2) loaves of raisin bread, one (1) package hamburger buns, two (2) loaves of white sliced bread which was opened and undated. An observation was conducted on 01/07/25 at 3:35 p.m. of the dry food storage area, accompanied by Employee #2 and Employee #3. The dry goods area was noted to have an open bag of partially used Oreo medium cookie pieces which some of the cookie pieces were hanging out of the open bag and no date on the open package. A Kool-Aid Twists were opened without a date. Also, was noted to have open cases of small can sodas that did not have a date when the case was opened for consumption, that included, but was not limited to: One (1) case of Shasta Root beer Soda which had four (4) unopened sodas not dated left within this case, one (1) case of Shasta Ginger Ale which had eight (8) unopened sodas not dated within this case, and one (1) case of Shasta Twist of eight (8) unopened sodas not dated within this case. A document titled: “Food and Nutrition Services ‘Used By’ Dating Guidelines” undated; was reviewed and stated in part: “The following is a guide to use when establishing a “Use By” date for food items...Guideline assume that food is properly stored, covered and handled. An interview was conducted on 01/07/25 at 3:25 p.m. with Employee #2, who confirmed that the bread and buns on the shelf was opened today during meal preparation which was not dated when opened. An interview was conducted on 01/07/25 at 3:40 a.m. with Employee #2, who confirmed that the Oreo Medium cookies pieces were not properly stored when opened and not dated, Kool-Aid Twist were not properly dated when the case was opened, and the Soda cases had unopened sodas left in the cases which was not properly dated when the soda cases where opened. Employee #2 stated, “When all these cases were opened, they should have been dated properly when opened.” An interview was conducted on 01/8/25 at 1:25 p.m. with Employee #1, who confirmed that the “Food and Nutrition Services ‘Use By’ Dating Guidelines is consider the guidelines or policy we use for dating and storage of food.””

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 40165 Based on observation, and staff interview, the facility failed to ensure that cooking equipment is protected in accordance with NFPA 96. This deficient practice could affect all residents, staff, and visitors. Facility census 9. Findings include: a) An observation on 1/7/25 at approximately 11:38 a.m., revealed a hood extingushing system without proper extingushing coverage over the griddle. b) These findings were verified during an exit interview with the Maintenance Director, and CEO on 1/09/25 at 11:30 a.m.”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This Standard is not met as evidenced by: 40165 Based on observation and staff interview, the facility failed to ensure that the facility was protected throughout by an approved automatic sprinkler system in accordance with NFPA (National Fire Protection Association) 13. This deficient practice could affect all residents, staff, and visitors. Facility census 9. Findings include: a) An observation on 1/7/25 at approximately 1:45 p.m.., revealed a sprinkler heads (3) in the Kitchen, near the dish area, that were corroded. b) These findings were verified during an exit interview with the Maintenance Director,and CEO on 1/09/25 at 11:30 a.m.”

“Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 This Standard is not met as evidenced by: 40165 Based on record review, observation, and staff interview between 1/7/25- 1/8/25 it was determined the facility failed to maintain electrical equipment within the facility. Facility census 9. a) Observation on 1/7/25 revealed an appliance cord that served a kitchen freezer, spliced, with exposed wire connectors, to make the chord longer to reach a receptacle. b) During record review on 1/08/25, findings revealed there was several failed damper tests with no corrective action for the following dampers: i. ID- 08696 ii. ID- 08686 c) These findings were verified during an exit interview with the Maintenance Director, and CEO on 1/09/25 at 11:30 a.m.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 40165 Based on record review, and staff interview, the facility failed to maintain Fire Doors in accordance with NFPA (National Fire Protection Association) 101 and 80. This deficient practice could affect all residents, staff, and visitors. Facility census 9. Findings include: a) Record review on 1/8/25 at approximately 9:00 a.m. revealed the facility failed to ensure that the fire rated doors in Hosptial were inspected annually. b)These findings were verified during an exit interview with the Maintenance Director, and CEO on 1/09/25 at 11:30 a.m.”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 40165 Based on record review and staff interview, the facility failed to maintain and test electrical receptacles at patient bed locations in accordance with NFPA (National Fire Protection Association) 99. Facility census 9. Findings include: a) Record review on 1/8/25 at approximately 10:35 a.m.., revealed no current documentation for testing of the physical integrity, correct polarity, continuity of the grounding circuit, or retention force for each electrical receptacle at the patient bed locations in the facility. b) These findings were verified during an exit interview with the Maintenance Director, and CEO on 1/09/25 at 11:30 a.m.”