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Based on observation and interview the facility failed to provide care in a safe setting. This deficiency is evidenced by toilets with ligature risk points at the base of the tank behind the toilet bowl in 12 ( a, b, c, e, f, g, p, q, x, Seclusion Y, Shower A, and Shower B) of 27 (a-x, Seclusion Y, Shower A, and Shower B) rooms on the unit with toilets for patient use.
Findings:

Tour of the unit on 05/31/2022 between 10:00 a.m. and 10:25 a.m. revealed the restrooms in patient rooms a, b, c, e, f, g, p, q.and x, Seclusion Y, Shower A and Shower B had space below the tank and behind the bowl which were ligature risk points. S2M and S4RN verified the findings during the tour.

In interview on 05/31/2022 at 11:09 a.m. S1Adm verified the toilets were a ligature risk.

Based on observation and interview the facility failed to maintain a clean and sanitary environment to avoid sources and transmission of infection. This deficiency is evidenced by soiled toilet seats in 6 (a, b, c, e, f, g) of 7 (a-g) toilet seats examined for cleanliness.
Findings:

Tour of the facility on 05/ 31/ 2022 between 10:00 a.m. and 10:25 a.m. revealed several toilets with hinged seats that had been fixed to the toilet bowel with a white substance. The surface of the white substance was irregular and the material was stained. The staining was verified by S2M and S4RN. It was noted that housekeeping had not yet cleaned the rooms and restrooms for the day.

A limited tour of the facility was performed on 06/01/2022 between 9:00 a.m.- and 9:10 a.m. Patient rooms a-g were inspected for cleanliness of the toilets.The staining of the substance between the toilet seat and the toilet rim had not been removed with regular cleaning in patient rooms a,b,c,e,f, and g.

During the tour between 9:00 a.m. and 9:10 a.m. S3DON verified the staining of the substance between the toilet seat and the toilet rim had not been removed with regular cleaning.

Based on record review and interview the facility failed to develop and implement policies and procedures to ensure all staff are fully vaccinated for COVID-19. This deficient practice was evidenced by failure to ensure 100% vaccination rate, excluding those staff who have been granted exemptions to the vaccination requirements, 60 days after implementation of CMS Omnibus COVID-19 Health Care Staff Vaccination Regulations.
Findings:

On 06/01/2022 a review of the vaccination information for all individuals who provide care, treatment, or other services for the center and/or its patients was performed. The total number of individuals providing care for the facility was 40. The fully vaccinated number was 37. There were 2 religious exemptions and no medical exemptions. One member of the direct care staff was unvaccinated and had not filed an exemption. The calculated vaccination rate was 97.5 %.

In interview on 06/ 01/2022 at 11:30 a.m. S3DON verified the COVID-19 vaccination information and S3DON verified that facility did not have 100% vaccination rate.