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Based on interview, observation, and review of the facility's monthly environmental round reports, the facility failed to provide patient care in a safe setting that reflected a failure to provide a well-maintained environment to a vulnerable population.

Findings:

During the initial tour at 12:05 PM, the West unit Restrain/Seclusion room #1 was toured. The following was observed:

1. The room revealed all walls had scraped paint revealing long scratches and graffiti in white where the blue/green paint had been scraped away. The largest area was approximately 1 and 1/2 feet in circumference.

2. The fluorescent light in the room, showed 9 small round paste-like protruding material attached to the light.

3. There were 2 round metal door stops observed on the West wall to protect the walls from the door knobs. The metal pieces were circular and approximately 2 and 1/2 inches in circumference. The wall plaster around the metal pieces was missing, and revealed a hole around the metal pieces which resulted in the ability to turn and loosen the door stop in the wall, which could be removed. Large areas of missing plaster was observed.

4. The room also showed missing base boards.

5. The patient bathroom between restraint rooms 1 and 2 had a cracked and missing portion of a marble threshold between the bathroom and restraint room 2. There was also a missing piece of tile at the bottom left of the door frame by the threshold.

On 7/08/19 at 12:30 PM, the Assistant Director of Nursing and the West Unit Nursing Manager revealed the Nurse Manager is responsible for monthly environmental round reports, which are submitted to the Facility's Manager/Safety Officer. The Nurse Manager retrieved the report which documented the condition of restraint room 1's walls needing base boards, paint and condition of the door stops. The Unit Manager related she had submitted the report as required for the end of June 2019 report and the areas had not been fixed.

A second tour and observation of restraint room 1 was completed with the Facilitiy's Manager/Safety Officer at 1:10 PM on 7/08/19. He related he was not aware of the condition of the restraint room regarding painting, and door stops. The Facility's Manager was shown the June 2019 environmental rounds report by the Unit Manager. The Facility's Manager/Safety Officer replied he had gotten the report, scanned it and did not realize the condition of the room. He related the 9 pieces of material on the light was sticky tape that had been used sometime to place a piece of paper over the light as it was too bright for the patient and should have been cleaned off.

6. The tour continued with the Facility's Manager/Safety Officer in the patient living area which showed the floor by the telephones had large white scratches underneath the chairs. The floor in front of the patient rooms H and I, along the north side of the unit, showed many circular areas approximately the size of an orange and smaller that were white and scattered around on the brown wood floor. The center of several of the circles were solid gray. On 7/08/19 at 1:18 PM, the Facility's Manager/Safety Officer related the circular areas were where the 40 pound chairs had rubbed the finish off of the floor, and the only thing that could be done was to replace the floor. The wood floors showed multiple areas of scraped and scuffed damage that were scattered about in the patient living area.