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Based on Policy review, observation, and interview, it was determined the physical environment was not maintained as a safe and functional environment throughout the facility to avoid sources and transmission of infection in that:
1.Throughout the facility showed:
a) Black/brown colored substance was present on the ceiling tiles.
b) Floor tiles had heavy dirt and grime buildup and was not sealed.
c) Floor tiles had broken areas.
2.Ceiling tile in medication room (Unit C and D) had black residue above the tile on the wall and was wet.
3.Throughout the Patient Rooms showed:
a) Patient showers had heavy dirt, grime, and black/brown residue between tiles.
b) Bathroom cabinets had missing Formica at the bottom showing wood that was porous and could not be properly disinfected.
c) Door frames had holes and peeling paint.

The failed practice had the likelihood to cause the spread and transmission of infection to all staff and patients in the facility.
The failed practice had the likelihood to effect all patients admitted to the facility. See A0750 for details.

Based on Policy review, observation, and interview, it was determined the physical environment was not maintained as a safe and functional environment throughout the facility to avoid sources and transmission of infection in that:
1.Throughout the facility showed:
a) Black/brown colored substance was present on the ceiling tiles.
b) Floor tiles had heavy dirt and grime buildup and was not sealed.
c) Floor tiles had broken areas.
2.Ceiling tile in medication room (Unit C and D) had black residue above the tile on the wall and was wet.
3.Throughout the Patient Rooms showed:
a) Patient showers had heavy dirt, grime, and black/brown residue between tiles.
b) Bathroom cabinets had missing Formica at the bottom showing wood that was porous and could not be properly disinfected.
c) Door frames had holes and peeling paint.

The failed practice had the likelihood to cause the spread and transmission of infection to all staff and patients in the facility.
The failed practice had the likelihood to effect all patients admitted to the facility. Findings follow:

A. Review of Policy and Procedure "Cleaning Public and Private Bathrooms", revised 04/20 showed the following:
1) Wipe any partitions with a damp sponge or cloth dipped in germicidal detergent solution.
2) Wipe down the tile walls behind toilets and urinals with germicidal solution.
B. Review of Policy and Procedure "Patient Rights and Responsibilities", revised 07/23, showed the patient had the right to expect reasonable safety in so far as the hospital practices and environment were concerned.
C. Review of the Patients' Rights, Responsibilities & Grievance showed the patient had the right to receive care in a safe setting.
D. Review of the Physical Environmental Tour documents from 04/12/2023 through 08/18/2023 showed ceiling tiles, walls, and flooring were in good condition. There was no evidence of a September 2023 Physical Environment Tour document.
E. During an interview on 10/03/23 at 10:00 AM, the Quality and Risk Manager confirmed A-D.
F. During observation on 10/02/23 at 1:45 PM showed the following:
1) Ceiling tile in medication room (Unit C and D) had black residue above the tile on the wall and was wet.
2) Throughout the facility:
a) Black/brown colored substance was present on the ceiling tiles.
b) Floor tiles had heavy dirt and grime buildup and was not sealed.
c) Floor tiles had broken areas.
3) Throughout the Patient Rooms showed:
a) Patient Showers had heavy dirt, grime, and black/brown residue between tiles.
b) Bathroom cabinets had missing Formica at the bottom showing wood that is porous and cannot be properly disinfected.
c) Door frames had holes and peeling paint.
G. During the observation on 10/02/23 at 2:30 PM, the Infection Control Coordinator and Plant Operations Manager confirmed the findings in F.