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Based on observation, interview, and record review the facility failed to provide and maintain a safe and sanitary environment for the census of 107 patients resulting in the potential for harm. Findings include:

During tour of the facility's 5 south unit on 04/16/24 at 1036, a sink was observed to be heavily discolored/rusted in the activity room. Director of Nursing, Staff C, was questioned why the white porcelain was missing from the basin of the sink? Staff C replied, "I've put in a work order already. The other sink on the unit is just as bad." The sink no longer had white porcelain finish protecting the sink basin and rusted bare metal was exposing approximately a six by six inch bare area. Staff C was asked to provide a copy of the work order and was requested to show the location of the second sink. The second sink was viewed and was not as severely damaged as the first, however, the missing finish appeared identical. Staff C stated, "Apparently we can't refinish the sink with porcelain here, because of the fumes it would present." Staff C provided a 'Work Order', #130886, dated 09/11/23, stating "Please refer to email in regards to sinks in dining room and day room."
On 04/17/24 at 1600, Staff C provided a purchase order (#1512570323) dated 04/16/24, indicating that three 'Ligature Resistant Stainless Steel Washbasins had been ordered.


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On 04/16/24 at 1120, during a tour of 6 South, a geriatric co-ed unit, room 618's bathroom was observed to be clean, except for the shower curtain, that was significantly stained with a dark brown substance covering the lower left corner of curtain and splash like brown marks noted higher on the curtain. P-8 residing in the semiprivate room was interviewed and stated, the toilet backed up with feces and exploded all over the floor last weekend and it took a long time (over 24 hours) for the toilet to be fixed and room to be cleaned. P-8 stated staff asked her to continue to use toilet (while waiting for it to be fixed) which was full of feces without flushing, and she refused. A bedside commode was observed in the room. P-8 stated she requested the dirty shower curtain be changed and it has not been, so now she cannot shower. At the time of observation, 6 South staff queried on toilet back up issue stated that patients put things in toilet like pads and gowns, which clog them up and at times cause an overflow. Director of Nursing (DON), Staff C who was escorting on tour queried on toilet issues and stated when clogged toilets occur, maintenance is contacted to fix, no explanation of why shower curtain not replaced was received.


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On 4/16/24 from 1035 to 1200 initial tour of the facility was conducted with Staff C. Multiple units were observed for patients and staff interactions, physical environment, cleanliness, and patient safety. Nursing station was observed on geriatric unit, 6 North. There was a blue Accu-Chek caddy (blood sugar test supplies kit) sitting on the desk in a corner. From the first glance, caddy appeared to be reachable from behind the counter of the nurses' station by an average height person. Surveyor went around the nurses' station counter, reached into the caddy, picked up several lancets (sharp needles) from it and put it in the pocket. Above actions were not noted by nursing staff present at the nurses' station. Several minutes later surveyor reached into the caddy again and picked up more lancets. Once again, it was unnoticed by staff. Staff C was present at the nurses' station at that time.

On 4/16/24 approximately at 1330 Staff C was shown the above-described lancets taken from caddy. Staff C was asked if all the units in the facility store their sharp supplies in spaces that can be accessed/reached by patients. Staff C stated that she was not sure and will check with all the facility units immediately. Staff C added that if any other similar equipment/supplies would be found, she will correct it immediately.

On 4/16/24 at 1200 to 1230 tour of the facility's 6 South Unit was conducted with Staff C. Unit was observed for patients and staff interactions, physical environment, cleanliness, and patient safety. Quiet room was open and available. Room was toured and was noted to have a broken window boarded with raw exposed plywood attached with multiple metal screws. One of the screws was observed to be sticking out of the wood about ¼ inch. Staff C was asked about the wood board. She stated that a patient damaged the window and facilities team boarded it from inside with plywood till window can be replaced. Further, bathroom was observed and noted to have a toilet full of water, toilet paper and feces. Staff C was asked if toilet was out of order. She stated that she was going to call facilities immediately to fix the toilet.

Room #662 was observed to have baseboard missing all around the perimeter of the room. Staff C stated that a patient torn the board several days ago and it was replaced by facilities. She added, that patient ripped the board again yesterday. It was not replaced yet.

Clean storage utility room was observed with Staff C. Multiple supplies (sleepers, biohazard bags) were noted to be lying on the floor. Clean patient gowns wrapped in a clear plastic were stored on the metal shelf approximately 6 to 8 inches from the ceiling with a sprinkle system. Staff C confirmed the findings.

Work order for broken window was requested and reviewed on 04/17/24. Work order number 132020 indicated:
Window broken. Needs replacing. 4/13/24 window company called but do not have an ETA (estimated time of arrival) yet. Temporarily boarded up. Submitted date: 4/12/24, area: 6S quiet room.