PRINTED: 04/11/2019 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ CA120000146 7 (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ADVENTIST HEALTH TULARE 869 N Cherry St Tulare, CA 93274 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) E000 Initial Comments ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE E000 The following reflects the findings of the California Department of Public Health during a Relicensing Survey. Representing the Department: 39602, HFEN 2706, HFEN 2227, Pharmaceutical Consultant Bed Capacity: 73 Census: 17 Sampled Patients: 34 E264 T22 DIV5 CH1 ART3-70213(a) Nursing Service E264 Policies and Procedures. 09/19/2019 (a) Written policies and procedures for patient care shall be developed, maintained and implemented by the nursing service. This Statute is not met as evidenced by: Based on interview and record review, the facility failed to follow its policy and procedure for blood glucose (BG - blood sugar) monitoring of a large for gestational age newborn (LGA) for one of 34 sampled patients (Patient 11). This failure had the potential to result in adverse outcomes for Patient 11. Normal BG for a newborn is greater than 40 milligrams per deciliter (mg/dL). LGA - a fullterm newborn weighing more than nine pounds, or 4082 grams (g). Findings: Licensing and Certification Division LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM 6899 XXEB11 TITLE (X6) DATE If continuation sheet 1 of 11 PRINTED: 04/11/2019 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ CA120000146 7 (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ADVENTIST HEALTH TULARE 869 N Cherry St Tulare, CA 93274 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with the Director of Obstetrical Services (DOS), on 9/18/19, at 10:10 AM, she reviewed the clinical record for Patient 11. The DOS stated LGA newborns should be fed within an hour of birth, then the BG should be checked half an hour after their first feeding. If the first BG is normal, the BG should then be checked every three hours for 12 hours. The DOS stated Patient 11 was feed within the first hour, but the BG's were not checked per policy. During review of the clinical record for Patient 11, the "Delivery Record" indicated Patient 11 was born on 9/4/19, at 2:01 PM. The History and Physical (H&P), dated 9/4/19, at 5:11 PM, written by Patient 11's pediatrician (MD 1), indicated Patient 11 was 4150 g at birth, and was diagnosed as being LGA. The section of the H&P titled "Orders", indicated ". . . do blood glucoses protocol." The "Blood Glucose, Capillary" results indicated Patient 11's BG was 87 mg/dL on 9/4/19, at 4:29 PM, and 64 mg/dL on 9/4/19, at 8:35 PM. There were no other BG results. During a review of the facility policy and procedure titled "Hypoglycemia (low BG) of the Neonate (newborn)" dated 7/6/19, it indicated ". . . A. Management of Hypoglycemic Infants (Screening Protocol): Refer to the attached algorithm." The attached algorithm indicated under "Asymptomatic (without symptoms) for '4 to 24 hours of age' 2. Screen glucose every 3 hours and prn (as needed). . . (... and LGA for 12 hours)." E294 T22 DIV5 CH1 ART3-70215(b) Planning and E294 09/26/2019 Licensing and Certification Division STATE FORM 6899 XXEB11 If continuation sheet 2 of 11 PRINTED: 04/11/2019 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: CA120000146 7 (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ADVENTIST HEALTH TULARE 869 N Cherry St Tulare, CA 93274 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Implementing Patient Care (b) The planning and delivery of patient care shall reflect all elements of the nursing process: assessment, nursing diagnosis, planning, intervention, evaluation and, as circumstances require, patient advocacy, and shall be initiated by a registered nurse at the time of admission. This Statute is not met as evidenced by: Based on interview and record review, the facility failed to develop and implement individualized, person-centered care plans for three of 34 sampled patients (Patient 20, Patient 25, and Patient 26). This failure had the potential to result in unmet care needs. 1. During a review of the clinical record for Patient 20, on 9/18/19, at 11:54 AM, Patient 20 was admitted to the hospital on 9/12/19. No evidence was found to indicate a care plan was developed to address discharge planning. During an interview with Registered Nurse (RN) 2, on 9/18/19, RN 2 stated Patient 20 should have had a care plan for discharge planning. 2. During a review of the clinical record for Patient 25, on 9/19/19, at 8:27 AM, Patient 25 was admitted to the hospital on 6/5/19 with a diagnosis of ulcer to the ankle. No evidence was found to indicate a care plan was developed to address Patient 25's wound to his ankle. During an interview with RN 2, on 9/19/19, at 8:29 AM, she confirmed there should have been a care plan initiated for the wound. 3. During a review of the clinical record for Patient 26, on 9/19/19, at 2:43 PM, Patient 26 was admitted to the hospital on 6/6/19 with a diagnosis of status post left ankle fusion. No Licensing and Certification Division STATE FORM 6899 XXEB11 If continuation sheet 3 of 11 PRINTED: 04/11/2019 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ CA120000146 7 (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ADVENTIST HEALTH TULARE 869 N Cherry St Tulare, CA 93274 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE evidence was found to indicate a care plan was developed to address Patient 26's left ankle fusion. During an interview with RN 2, on 9/19/19, at 2:44 PM, she stated Patient 26 should have had a care plan to address the patient's pertinent issues. During a review of the facility policy and procedure titled "Organizational Plan for the Provision of Patient Care and Services" dated 10/8/18, it indicated "b. . . . As such, nursing includes the recognition of priority health care needs, pain management, maintain dignity and patient rights, health care teaching, managing interdisciplinary patient care and patient advocacy. Nursing services are provided on an atmosphere of collaboration, both interdependently and independently with other health care disciplines throughout the organization." E475 T22 DIV5 CH1 ART3-70263(c)(1) E475 Pharmaceutical Service General Requirements 10/10/2019 (1) The committee shall develop written policies and procedures for establishment of safe and effective systems for procurement, storage, distribution, dispensing and use of drugs and chemicals. The pharmacist in consultation with other appropriate health professionals and administration shall be responsible for the development and implementations of procedures. Policies shall be approved by the governing body. Procedures shall be approved by the administration and medical staff where such is appropriate. Licensing and Certification Division STATE FORM 6899 XXEB11 If continuation sheet 4 of 11 PRINTED: 04/11/2019 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: CA120000146 7 (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ADVENTIST HEALTH TULARE 869 N Cherry St Tulare, CA 93274 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This Statute is not met as evidenced by: Based on interview and record review, the hospital failed to ensure the removal of fentanyl (a potent opioid controlled substance) transdermal (absorbed through the skin) patches was documented by licensed staff for one of 34 sampled patients (Patient 33). This failure had the potential to result in diversion of controlled substance to go unnoticed and could potentially put patient and staff at risk of harm due to misuse of this medication. Findings: During a concurrent interview with the Pharmacist-In-Charge (PIC) and review of the Medication Administration Record (MAR) for Patient 33, on 9/18/19, at 2:36 PM, the MAR dated 12/12/18 indicated Patient 33 had the following medication order: "Fentanyl Patch 12 mcg (microgram), apply a new patch every 72 hours." The MAR indicated a fentanyl patch was applied to Patient 33 on 12/12/18, at 11:56 AM. A new fentanyl patch was applied to Patient 33 on 12/15/18, at 8:41 AM. There was no documentation in Patient 33's record that the old fentanyl patch was removed from Patient 33 by the nurse for proper disposal and destruction. During an interview with the PIC, on 9/18/19, at 2:49 PM, she confirmed there was no documented record of removal or disposal of the used fentanyl transdermal patch when a new fentanyl patch was applied to Patient 33. The prescribing information from a manufacturer of fentanyl transdermal patches indicated "A considerable amount of active fentanyl remains in fentanyl transdermal system even after use as directed. . . fentanyl transdermal system exposes patients and other Licensing and Certification Division STATE FORM 6899 XXEB11 If continuation sheet 5 of 11 PRINTED: 04/11/2019 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: CA120000146 7 (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ADVENTIST HEALTH TULARE 869 N Cherry St Tulare, CA 93274 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE users to the risks of opioid addiction, abuse, and misuse, which can lead to overdose and death." The accidental exposure section of the Black Box Warning (the most serious medication warning required by the U.S. Food and Drug Administration indicated "Accidental exposure to even one dose of fentanyl transdermal system, especially in children, can result in a fatal overdose of fentanyl. Deaths due to an overdose of fentanyl have occurred when children and adults were accidentally exposed to fentanyl transdermal system. Strict adherence to the recommended handling and disposal instructions is of the utmost important to prevent accidental exposure." Licensing and Certification Division STATE FORM 6899 XXEB11 If continuation sheet 6 of 11 PRINTED: 04/11/2019 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ CA120000146 7 (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ADVENTIST HEALTH TULARE 869 N Cherry St Tulare, CA 93274 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) E558 T22 DIV5 CH1 ART3-70273(l)(1) Dietetic Service General Requirements ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE E558 09/22/2019 E587 09/22/2019 (1) All kitchens and kitchen areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. This Statute is not met as evidenced by: Based on observation and interview, the facility failed to maintain a sanitary environment in the kitchen. This failure had the potential to result in the spread of infection to staff, patients, and visitors. Findings: During an observation on 9/18/19, at 1:49 PM, in the kitchen next to the ice machine, a floor drain was noted to have a grayish substance on the floor area surrounding the drain and under the ice machine. Three pipes led to the drain. A large white pipe leading from a kitchen sink to the floor drain had liquid dripping into the floor drain. During an interview with Dietary Manger (DM) 2, on 9/18/19, at 1:52 PM, he stated the grayish substance was food debris from the white pipe coming from the kitchen sink. A facility policy and procedure was requested, and not provided. E587 T22 DIV5 CH1 ART3-70277(b)(2) Dietetic Service Equipment and Supplies (2) All food shall be of good quality and procured from sources approved or considered satisfactory by federal, state and local authorities. Food in unlabeled, rusty, leaking, Licensing and Certification Division STATE FORM 6899 XXEB11 If continuation sheet 7 of 11 PRINTED: 04/11/2019 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ CA120000146 7 (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ADVENTIST HEALTH TULARE 869 N Cherry St Tulare, CA 93274 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE broken containers or cans with side seam dents, rim dents or swells shall not be accepted or retained. This Statute is not met as evidenced by: Based on observation, interview, and record review, the facility failed to appropriately label and store raw almonds. This failure had the potential to result in food of diminished quality to be served to patients. Findings: During an observation of the dry food storage area and interview with Dietary Manager (DM) 1, on 9/18/19, at 1:40 PM, there were raw almonds in a clear plastic container on a shelf. The container was labeled "8/11/19. . . Use by 9/11/19." DM 1 stated the almonds had been removed from a plastic package and placed in the plastic container on 8/11/19. DM 1 stated dietary staff refers to the "Guidelines for Food Storage" posted on a nearby door to determine how long to store the food. DM 1 reviewed the Guidelines and stated raw almonds removed from original packaging are good for seven days. DM 1 stated the almonds should have been labeled with a "use by" date of 8/18/19, and discarded at that time. During a review of the facility's "Nutritional Services - Guidelines for Food Storage" dated 6/09, it indicated "Food item: Raw almonds portioned. Length for storage: 7 days." E2382 T22 DIV5 CH1 ART8-70847 Infectious Waste E2382 09/20/2019 Infectious waste, as defined in Health and Safety Code Section 25117.5, shall be handled and disposed of in accordance with the Hazardous Waste Control Law, Chapter 6.5, Licensing and Certification Division STATE FORM 6899 XXEB11 If continuation sheet 8 of 11 PRINTED: 04/11/2019 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: CA120000146 7 (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ADVENTIST HEALTH TULARE 869 N Cherry St Tulare, CA 93274 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Division 20, Health and Safety Code (beginning with Section 25100) and the regulations adopted thereunder (beginning with Section 66100 of this Title). This Statute is not met as evidenced by: Based on observation, interview, and record review, the facility failed to follow its policy and procedure for disposal of infectious waste products. This resulted in infectious waste being stored past its disposal date. Findings: During an observation on 9/17/19, at 11 AM, inside the obstetrics dirty storage room, a refrigerator contained a white plastic container with a date of 9/15/19 hand-written on the lid. During an interview with Registered Nurse (RN) 1, on 9/17/19, at 11:01 AM, she stated the plastic container contained a placenta (a large organ which develops during pregnancy) from Patient 28, who delivered on 9/7/19. She stated 9/15/19 was the disposal date and the plastic container should have been discarded after that date. During an interview with Environmental Services (EV) 1, on 9/19/19, at 10:27 AM, she stated when nurses place the placenta inside the refrigerator, they place it in a white bucket with a date written on it. EV 1 stated seven days after that date, environmental services places it in a red bag to be disposed of. During a review of the facility policy and procedure titled "Placenta Handling and Disposal" dated 3/14/19, it indicated "B. Placentas shall be retained and stored in a specimen container 'after delivery date' and refrigerated for seven (7) days in the event a pathology examination is required. After seven Licensing and Certification Division STATE FORM 6899 XXEB11 If continuation sheet 9 of 11 PRINTED: 04/11/2019 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ CA120000146 7 (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ADVENTIST HEALTH TULARE 869 N Cherry St Tulare, CA 93274 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (7) days, the Environmental Services department shall: 1. Place placentas in a red biohazard bag until such time they shall be transported." E2444 T22 DIV5 CH1 ART8-70863(b) Water Supply and Plumbing E2444 10/10/2019 (b) Plumbing and drainage facilities shall be maintained in compliance with Part 5, Title 24, California Administrative Code, Basic Plumbing Requirements. Drinking water supplies shall comply with Group 4, Subchapter 1, Chapter 5, Division T17, Part 6, of Title 24, California Administrative Code. This Statute is not met as evidenced by: Based on observation and interview, the facility failed to maintain its plumbing and drainage system. This failure had the potential to result in the spread of infection. Findings: During an observation on 9/17/19, at 9:22 AM, inside Emergency Department (ED) patient treatment room 2, a brown substance was noted on the floor under the sink. During an interview with the Director of Med/Surg (DMS), on 9/17/19, at 9:24 AM, she stated the brown substance looked like rust. During an interview with the Facilities Associate (FA), on 9/17/19, at 10:25 AM, he stated, "It was probably water, it was something rusted." During an observation on 9/17/19, at 11:19 AM, inside Intensive Care Unit (ICU) room 288, a brown substance was noted on the floor under Licensing and Certification Division STATE FORM 6899 XXEB11 If continuation sheet 10 of 11 PRINTED: 04/11/2019 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: CA120000146 7 (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ADVENTIST HEALTH TULARE 869 N Cherry St Tulare, CA 93274 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the sink. During an interview with the Director of ED/ICU (DEI), on 9/12/19, at 11:21 AM, he stated, "It's something dripping from the pipes, it's rust." During an observation on 9/17/19, at 11:28 AM, inside ICU room 287 (a negative pressure room used to contain airborne contaminants within the room), a brown substance was noted on the floor area and the walls under the sink. During an interview with the Assistant Director of Facilties (ADF), on 9/17/19, at 11:36 AM, he stated, "It's looks like a leaky drain, it's just leaking and flaking." A facility policy and procedure was requested, but not provided. Licensing and Certification Division STATE FORM 6899 XXEB11 If continuation sheet 11 of 11