HospitalInspections.org

?482.12 Condition of Participation: Governing Body - NOT MET

Based on interviews and record reviews, the hospital failed to:
? ensure proper professional standards of practice related to food safety were followed. (A-0083)
? ensure food was prepared, stored and served in a safe manner by foodservice operation, identified as TT's Cafe. (A-0084)
? ensure that TT's Cafe was licensed as a restaurant. (A-0085)

The totality of these issues put at risk each inpatient, visitor and staff who purchased food at TT's Cafe on 4/22/2013, 4/23/2013 and 4/24/2013, resulting in Wisconsin's Public Health agency closing it down.

Based on interviews and record reviews, the governing body of the facility failed to ensure that the foodservice operation, identified as TT's Cafe, was following proper professional standards of practice related to food safety. This had the potential to put all inpatients, visitors and staff at risk for a foodborne illness.

Findings include:
See findings under A0618, A0619 and A0622

Based on interviews and record reviews, the governing body of the facility failed to ensure the following:

* Food is prepared, stored and served in a safe manner by contracted food service operation located in the hospital in 1 of 2 food prep areas observed (TT Cafe). This has the potential to affect all inpatients, visitors, and staff who purchase food from the cafe.

* Windows were adequately cleaned and maintained under contracted janitorial service in 2 of 4 units observed (43 A, 53 B).
A referral was made to Wisconsin's Public Health department which resulted in the cafe being closed down (cross reference A0618, A0619 and A0622) This had the potential to effect all 78 patients receiving treatment at this facility.

Findings include:

Food Service area, known as TT's Cafe, located in hospital, was operating as a restaurant, without a license and storing, preparing and serving food in an unsafe manner ultimately putting patients/families/visitors at risk for foodborne illness. There were no guidelines or implementation of guidelines for acceptable hygiene practices and kitchen sanitation.

According to the Journal of Food Protection, Vol. 75, No.12, 2012, Pages 2173-2178 ["Restaurant Food Cooling Practices, "
" Improper cooling of hot food by restaurants is a significant cause of foodborne illness."] On 4/25/2013, referral was made to Wisconsin's Department of Public Health and TT's Cafe was closed down.

On 4/24/13 from 2:45 p.m. to 4:07 p.m. the following observations were made in the area of TT's Cafe:
? Improper cooling of foods
? Hands not washed as required - using hand sanitizer instead of washing hands
? No handwashing sink.
? Food items unlabeled/not dated
? Dirty equipment and single-use disposable items
? Food stored in inappropriate containers
? Food items commingled with maintenance tools
? No system in place to ensure sanitizing solution is at correct strength - potential to be at toxic levels when smell is used for determination.
? Single-use items stored incorrectly, contaminating eating/drinking surface
? Counter tops and shelving dirty and chipped
? Serving utensils stored inside container and bag of ice
? No thermometers for checking temperatures of food items
? No thermometers for checking cooler/freezer temperatures
? Items stored directly onto floor
? Garbage receptacles without lids

On 4/24/13 at 3/54 p.m. to 4:00 p.m., surveyor showed O-KK pork soup cooling on the counter. O-KK stated that is was not appropriate. There should be ice added to cool it down, or use a cooling device such as an ice paddle. That is how O-KK stated items at O-KK's other place are cooled.


15410

1. Observation on 04/22/13 included a tour of the 5-53 B Adolescent Inpatient Unit from 10:55 a.m. to 12:05 p.m. and 2:25 p.m. to 3:25 p.m. accompanied by Nursing Program Coordinator (NPC) M.

Observation at 11:00 a.m. identified Room #1 with a double paned window to the outside with cobwebs covering the entire bottom, inside the double paned glass. The room was currently occupied by 2 patients. During the interview at 11:00 a.m., NPC M stated the window would have to be disassembled in order to clean inside the panes of glass.

Observation at 2:50 p.m. identified Room #38 with a double paned window to the outside with cobwebs covering the entire bottom, inside the double paned glass, greater on the right than the left. The room was currently occupied by 1 patient. During the interview at 2:50 p.m., NPC M stated that since the window was bolted shut, there would have to be a joint effort between housekeeping and maintenance to clean it.

Per review on 4/24/13 of the contract with UU (undated), it stated under Behavioral Health Department-Psychiatric Hospital - pg. 27: Those items requiring periodic cleaning such as windows and window coverings will be cleaned at the specific intervals by prior arrangement with the Contractor and management. There was no specific cleaning identified of the areas in between the double paned windows.

Based on requests, the only documents provided related to TT's Cafe were two licenses that pertained to other establishments and not the hospital.

On 4/24/2013, 3:54 PM, location of TT's Cafe, owner-KK (OBC-KK) reports does not have a restaurant license for TT's Cafe. OBC-KK stated was asked by Vending Machine Vendor (VMV-SS) to come in and run the cafe, after "Easter Seals," left. OBC-KK stated began operation of cafe in November, 2012.

On 4/25/2013, 12:01 PM, received from Director of Operations(DO), copies of OBC-KK licenses (for other establishments) from State of Wisconsin, Department of Health Services, Division of Public Health, "Restaurant - High Complexity," " Not Transferable, " I.D. Number JPFR-8X5L2R, and for a BUSINESS/ESTABLISHMENT, in Delavan, WI - not at the hospital. The other is for a " Temporary Restaurant - Temporary, " " Not Transferable, " I.D. Number KBRN-8JJPKA, and for a BUSINESS/ESTABLISHMENT, in Delavan, WI - not at the hospital. These two licenses, which are not transferable to the hospital's operation, were not on file at the hospital, but were provided upon request via Director of Operations -X. Facility has not provided any other documentation specific to TT's Cafe.

Based on observations, 5 patient interviews (#7, #22, #31, #32, #33), 3 staff interviews (OT OO, IDN D, CRS Z) and record reviews, patients are not aware of their right to private, personal calls. This can potentially affect all 78 patients receiving treatment at this facility.

Findings are as follows:

On 4/23/13, 11:45 AM, review of Policy & Procedure "PATIENT RIGHTS POLICY AND PROCEDURE," Policy Number ADM #020, and last date revised, 2/1/11, bullet number 18, states "Each Patient shall be permitted to make a reasonable number of private, personal calls. Patient's yellow handout (located in "ACUTE INPATIENT ORIENTATION MATERIALS " ), "Client Rights & Grievance Procedure," dated 4/18/11, does not address the right to privacy during phone calls based on the un-numbered bullet which states "You have the right to use a telephone daily, but the staff can impose reasonable limits on your use of the telephone."

On 4/22/13, area 43-A, 10:38 AM observed Pt #8 on wall phone in hallway and heard conversation from nurses' station about pt. going home. There was no privacy during the call. Pt #7 was walking up to Pt #8 while on the phone. At 10:41 AM, observed Pt #7 was on wall phone with staff and other patients in the area.

On 4/24/13, area 43-A, 9:38 AM, asked Pt #33 where would one go to make a private call. Pt #33 stated does not know - would probably have to use the phone on the wall. Pt #33 stated has seen people on the wall phone and could hear what was being said if Pt #33 wanted to listen.

On 4/24/13, area 43-A, 9:42 AM, asked Pt #32 where would one go to make a private call? Pt #32 stated there is no privacy whatsoever - would not know where to make a private call or who to ask to be able to make a private call. Pt #32 thought the phone on the wall was the only one they could use.

On 4/24/13, area 43-A, 9:47 AM, conducted a group interview regarding what does one do to make a private call? Pt #31 stated there might be privacy but there are a lot of people walking around though. Pt #7 stated can only use one phone - the phone on the wall. Pt #7 stated there "ain't any privacy." Pt #7 stated the wall phone is located where all the traffic is; there isn't any privacy. Staff OTR-OO stated patients can use exam room but Staff IDN-D stated could not be alone in there due to safety reasons. Pt #22 stated since when can we use exam room to make private calls? IDON D stated will have to work on finding a safe, private area for telephone calls.

On 4/24/13, 11:11 AM, interviewed Staff CRS Z who stated patients do need privacy to make telephone calls. CRS Z stated there is no place for them to have a private area to make a phone call.

Based on observation and staff interview the hospital failed to ensure the physical safety of patients in 2 of 4 units observed (43 A, 53 B) This had the potential to affect all patients receiving treatment at this facility.

Findings include:

1. Observation on 04/22/13 included a tour of the 5-53 B Adolescent Inpatient Unit from 10:55 a.m. to 12:05 p.m. and 2:25 p.m. to 3:25 p.m. accompanied by Nursing Program Coordinator (NPC) M.

Observation during the morning and afternoon tours on 04/22/13 identified there were no functional call buttons in several patient rooms, bathrooms, and common areas. Further observation on 04/23/13 during both morning and afternoon tours, identified there was no functional call system anywhere on the unit.

During interview with NPC M on 04/24/13 at 3:25 p.m., NCP M confirmed there was no functional call system on the unit. Without a functional call system in areas from which patients may need to summon assistance (including patient rooms and bathrooms), placed the patients who resided on 5-53 B at risk.

2. Observation on 04/22/13 included a tour of the 5-53 B Adolescent Inpatient Unit from 10:55 a.m. to 12:05 p.m. and 2:25 p.m. to 3:25 p.m. accompanied by Nursing Program Coordinator (NPC) M with the following concerns noted.

Observation at 11:10 a.m. in Room 3305-4 (locked tub room) identified a shower area as well as a stand-up scale in the room. In the shower area there were 3 wall tiles that had the heads of metal-looking nails or screws protruding slightly outward which were sharp to the touch. NPC M stated she was unsure if patients used the shower.

Observation at 11:15 a.m. in Room 8 (locked bathroom) identified a bathroom consisting of a sink and toilet. On the right side of the toilet it was noted that the heads of 4 metal-looking nails or screws protruded slightly outward which were sharp to the touch. NPC M stated she was unaware of the reason why these metal nails or screws were there and identified that both patients and staff used the bathroom (staff unlocked the bathroom for patient use).

Observation at 11:30 a.m. in the "Conference Room" (open to all patients) identified a row of 6 large cupboard doors against the wall on the right side of the room. All of the cupboard doors were locked except the second to the last cupboard door (as one entered the room). A table rested in front of this cupboard door and it was noted there was a small hole where the lock mechanism should have been. When the table was moved and the cupboard door opened, it was identified there were 5 black metal brackets on the bottom shelf of the cupboard which were sharp to the touch. NPC M removed the brackets and stated in interview at that time that the cupboard door should have been locked.

Observation at 2:25 p.m., in Room 26, (a locked restraint/seclusion room) identified inside the room was a locked bathroom. When the bathroom was unlocked, it was noted on 1 of the ceramic tiles in the shower that the head of 1 metal-looking nail or screw protruded slightly outward which was sharp to the touch. NPC M stated she was unaware of the reason why these metal nails or screws were there.


20878


During a tour of unit 43-A on 04/23/13 at 3:40 PM with Unit Manager Q it was observed that a regular hospital bed (made of metal and on wheels) was being used for a patient in room #7. Q said at the time of the tour that the bed was being used to allow double occupancy of the room. Q agreed that the bed could potentially be dismantled by a patient for weapons (to harm selves or others) or be rolled against the door for barricading. Per interview with DON D on 04/23/13 at 4:10 PM there is no policy which speaks directly to restriction of the use of such a bed.

Based on medical record review, staff interview, and Medical Staff Rules and Regulations the facility staff failed to ensure all medical records are complete, signed, timed, and dated in 9 of 30 ( Pt # 12, 14, 15, 23, 24, 25, 26, 27, 28) medical records reviewed. This could potentially affect all patients receiving treatment at this facility.

Finding include:

Review on 4/23/13 of Medical Staff Rules and Regulations dated December 2012 reveals the following: 2.6.1--All entries in the record shall be accurately dated, timed, and authenticated by authorized health care personnel.

Per medical record review of pt. # 12 on 4/23/13 at 2:20 PM noted a discharge summary dated and signed but no MD signature noted.

Per medical record review of pt. # 14 on 4/23/12 at 12:00 PM noted Discharge summary signed by MD but no date or time is recorded.

Per medical record review of pt. # 15 on 4/24/13 at 10:30 am noted pt. #15 had admission orders signed on 4/19/13 at 8:30 PM indicating Suicide Observation Status Level 2 (Every 15 minute checks). Documentation on checks/observation sheet indicated that pt. # 15 was checked at 11:00 PM and then was not checked again until 11:30 PM. Staff then continued with every 15 minute checks until 1:15 am, next check noted at 1:30 am. Check completed at 1:45 am and next check noted to be 2:30 am. Checks and observation sheet dated 4/20/13 indicated checks completed until 11:30 am, next check is not documented until 2:45 PM. This MR was not complete.

Above findings verified by IDON D on 4/24/13 at 11:30 am. IDON D discussed with RN S if she knew why 15 minute checks were not completed as ordered and RN S stated no.


29972


Per review of Pt #23's MR on 4/23/13 beginning at 10:45 am , the "Initial Nursing Assessment" dated 4/6/13 at 8:10 PM reveals no documentation under the categories of "Chief Complaint" "Acute Behavior that caused this visit" and "The patient is on ED. Describe dangerous behavior". The "PM Acute Adult Nursing Assessment Flow and Daily Progress Notes" dated 4/7/13 and 4/9/13 are not timed; Nursing Assessment Flow sheet dated 4/9/13 at 10:00 am reveals no documentation under "Behavior Risk" assessment category. Nursing Assessment Flow sheet dated 4/9/13 on PM Shift (no time documented) reveals no documentation of "Cardiovascular" and "Respiratory" assessment categories. Pt #23's Recovery Plan side 2 reveals no patient signature or box checked of patient refusing to sign.

Review of Pt #24's MR on 4/23/13 beginning at 11:30 am reveals the following; "BHD Community Services Consultation Note" dated 1/30/13 is not timed; "Nursing/Physician Discharge Instructions" is not timed; no patient signature of box checked of patient refusing to sign on the Recovery Plan side 2; "Initial Psychiatric/Psychological Database" is not signed, timed, and dated by physician; Morse Fall Scale assessment dated 1/23/13 contains no time.

Review of Pt #25's MR on 4/23/13 beginning at 2:00 PM reveals the following; Physician Admission Orders dated 3/27/13 contain no time and date of RN's signature; "Nursing/Physician Discharge Instructions" dated 4/3/13 is not timed; "Initial Psychiatric/Psychological Database" dated 4/3/13 is not timed; PM Shift Nursing Assessment Flowsheet dated 3/27/13 is not timed and Cardiovascular, Respiratory, and Gastrointestinal Assessment categories are blank; AM Nursing Assessment Flowsheet dated 3/29/13 and 3/30/13 are not timed.

Review of Pt #26's MR on 4/25/13 beginning at 8:30 am reveals the following: Discharge Summary dated 3/19/13 not timed; "BHD community Services Consultation Note" dated 12/27/12 not timed; Physician Admission Order Form dated 12/25/12 not timed by RN; Broset Violence Checklist dated 12/25/12 is incomplete; Attending Medical Staff Discharge Order Form does not include date and time physician signed. Nursing/Physician Discharge Instructions dated 1/7/13 at 2:03 PM is incomplete, no documentation under "Mode" of discharge, "Accompanied by", "Transportation", "Valuables/ Personal Belongs" or "Signature of Person Receiving Valuables/Personal Belongings", page 2 of discharge instructions do not contain a time of RN and SW signing, no patient signature documented of understanding and receiving discharge instructions. "Recovery Plan" side 2 is incomplete, "Working Diagnosis" is blank. RN Physical Assessment Screen dated 12/25/12 is not timed. Morse Fall Scale assessment form dated 12/25/12 is not timed.

Review of Pt #27's MR on 4/25/13 beginning at 9:30 am reveals the following: "Request for Referral/Transfer to PCS" form dated 4/9/13 is not timed; "BHD Community Services Consultation Note" dated 4/10/13 is not timed; "Attending Medical Staff Discharge Order" form does not contain time and date physician signed; "Nursing/Physician Discharge Instructions" dated 4/16/13 is not timed; "Recovery Plan" side 2 does not have patient signature or box checked of patient declining to sign. "Assessment and Progress Record For Seclusion/Restraint" form dated 4/9/13 is incomplete, "Description of Debriefing Process with Patient" section is blank. RN Seclusion/Restraint progress record dated 4/10/13, 4/11/13, 4/12/13, 4/13/13, 4/14/13, and 4/15/13 reveals incomplete and inconsistent documentation of physical status, circulation, respiratory, pain/discomfort, mental status, mood, readiness for release, and hydration status assessments as per facility policy and procedure.

Review of Pt #28's MR on 4/25/13 beginning at 11:00 am reveals the following: "BHD Community Services Consultation Note" dated 1/11/13 is not signed and timed; "Nursing/Physician Discharge Instructions" dated 1/15/13 is not timed; "Recovery Plan" side 2 does not contain patient signature or box checked of patient declining to sign; "Initial Psychiatric/Psychological Database" form dated 3/19/13 is not timed; "Morse Fall Scale" form assessment dated 1/11/13 is not timed.

The above findings were confirmed with CCO B on 4/25/13 beginning at 12:00 PM, Per CCO B all entries in the medical record should be signed, timed, and dated. Per CCO B all categories of the Nursing Assessment Flow sheet should be complete and initialed by nursing staff if "Standard Met".

Based on medical record review and Medical Staff Rules and Regulations the facility failed to ensure verbal (VO) and telephone orders (TO) are authenticated by a Medical Doctor (MD) with a signature, date, and time in 9 of 30 ( Pt # 16,18,19,20,22,24,25,26,27) medical records reviewed. This can potentially affect a patients receiving treatment at this facility.

Findings Include:

Review on 4/23/13 of Medical Staff Rules and Regulations dated December 2012 reveals the following: 2.6.1--All entries in the record shall be accurately dated, timed, and authenticated by authorized health care personnel.
2.6.3.1--All acute inpatient and crisis observation service verbal and telephone orders shall be counter-signed, dated, and timed within 48 hours by the authorized member of the Medical Staff that originated the order.

Review of Pt #24's MR on 4/23/13 beginning at 10:45 am reveals the following: telephone order to change Aricept dose dated 2/1/13 at 9:10 am contains no time and date of physician authentication.

Review of Pt #25's MR on 4/23/13 beginning at 2:00 PM reveals the following: telephone order to have sutures evaluated by medical team for removal dated 3/27/13 at 6:50 PM is not signed, timed, and dated by physician; telephone order to hold lisinopril based on BP parameters is not signed, timed, and dated by physician.

Review of Pt #26's MR on 4/25/13 beginning at 8:30 am reveals the following: verbal order to start "finger sticks" twice daily dated 12/31/12 at 12:45 PM contains no time and date of physician authentication.

Review of Pt #27's MR on 4/25/13 beginning at 9:30 am reveals the following: telephone orders for Seclusion Restraint Physician extension orders dated 4/9/13 at 9:15 am, 1:15 PM, 5:15 PM, 9:15 PM, 1:15 am; 4/10/13 at 5:15 am; 4/11/13 at 7:00 PM; 4/12/13 at 7:00 am and 10:30 PM; 4/13/13 at 6:30 am, 6:30 PM, 10:30 PM; 4/14/13 at 2:30 am, 6:30 am; 4/15/13 at 2:30 am, 6:30 am, 10:30 am, 2:30 PM are not signed, timed, and dated by physician.

The above findings were shared with CCO B (Chief Compliance Officer) on 4/25/13 beginning at 12:00 PM.


20878

Patient (Pt) #16's medical record review on 4/22/13 at 1:45 PM revealed a TO for restraint written on 4/11/13 that is not authenticated by an MD with a signature and/or date and time. This is confirmed in interview with IDON D on 4/22/13 at 2:30 PM.

Pt #18's medical record review on 4/22/13 at 3:30 PM revealed a TO for labs written on 4/12/13 that is not authenticated by an MD until 04/15/13 (>48 hours). This is confirmed in interview with IDON D on 4/22/13 at 3:30 PM.

Pt #19's medical record review on 4/22/13 at 2:30 PM revealed a TO for restraint written on 4/12/13 that is not authenticated by an MD until 04/15/13 (>48 hours). This is confirmed in interview with IDON D on 4/22/13 at 2:30 PM.

Pt #20's medical record review on 4/23/13 at 10:30 AM revealed there are TO's for restraints written on 4/10/13 and 4/11/13 that are not authenticated by an MD with a signature and/or date and time. This is confirmed in interview with IDON D on 4/23/13 at 11:00 AM.

Pt #22's medical record review on 4/23/13 at 3:00 PM revealed there are TO's for restraints written on 4/5/13 and 4/10/13 that are not authenticated by an MD with a signature and/or date and time. This is confirmed in interview with IDON D on 4/23/13 at 3:30 PM.

Based on observations and staff interview, the hospital failed to ensure medications were properly stored and that outdated biologicals were not available for patient use. This could potentially affect all 78 patients receiving treatment at this facility.

Findings include:

Per tour of unit 43-B on 4/22/13 between 10:00 AM and 11:00 AM with DON D, observations in room 11 revealed: 4 outdated culture swabs (1 expired on 01/2013, 3 expired on 04/2013), 3 outdated specimen tubes (all expired on 02/12/2013) and 1 outdated mineral oil enema (expired on 06/2011). The medication room of unit 43-B contained a glucagon emergency kit (treatment for severe low blood sugar) with an expiration date of 07/2012. DON D said at the time of the tour that these outdated items should have been removed and replaced.


29963


Per tour on 4/22/13 at 11:35 am of Unit 43C, noted a 1000 cc plastic bottle of Normal Saline 0.9% in treatment exam room in cupboard dated 1/13.

Findings verified with ADM A on 4/22/12 at 11:40 am.

Based on observations, interviews, record reviews (refer to A0622), the facility did not ensure that food and dietetic services organization requirements are met. Dietary Supervisor G states does not provide any oversight or monitoring of TT's Cafe This had the potential to negatively impact on all inpatients, staff and visitors on 4/22/2013, 4/23/2013 and 4/24/2103. (A0619)

Based on observations, interviews and record reviews, the facility did not provide to the patients a substitute of equal nutritional value during noon mealtime on 4/22/2013, for the following individuals: Pt 1, Pt 2, Pt 4 and Pt 6. negatively impacting 4 out of 10 patients on children ' s unit-53B. (A-0628)

Food Service area, known as TT's Cafe, located in hospital, was operating as a restaurant, without a license and storing, preparing and serving food in an unsafe manner ultimately putting patients/families/visitors at risk for foodborne illness. There were no guidelines or implementation of guidelines for acceptable hygiene practices and kitchen sanitation. This had the potential to negatively impact all inpatients, staff and visitors on 4/22/2013, 4/23/2013, 4/24/2013. (A0622)

According to the Journal of Food Protection, Vol 75, No.12, 2012, Pages 2173-2178 ["Restaurant Food Cooling Practices, "
" Improper cooling of hot food by restaurants is a significant cause of foodborne illness."] On 4/25/2013, referral was made to Wisconsin's Department of Public Health and TT's Cafe was closed down. The 2009 Food and Drug Administration Food Code (professional standard that Dietary Supervisor G states is the professional standard of practice used) identifies hands as a vehicle of contamination and an effective management system for preventions needs to be in place.

An observation on 4/24/13 from 2:45 p.m. to 4:07 p.m. indicated that basic operational and sanitation programs were not in place based on the following:
? Improper cooling of foods
? Hands not washed as required - using hand sanitizer instead of washing hands
? No handwashing sink.
? Food items unlabeled/not dated
? Dirty equipment and single-use disposable items
? Food stored in inappropriate containers
? Food items commingled with maintenance tools
? No system in place to ensure sanitizing solution is at correct strength - potential to be at toxic levels when smell is used for determination.
? Single-use items stored incorrectly, contaminating eating/drinking surface
? Counter tops and shelving dirty and chipped
? Serving utensils stored inside container and bag of ice
? No thermometers for checking temperatures of food items
? No thermometers for checking cooler/freezer temperatures
? Items stored directly onto floor
? Garbage receptacles without lids

Based on observations, interviews, record reviews (refer to A0622), the facility did not ensure that food and dietetic services organization requirements are met. Dietary Supervisor G states does not provide any oversight or monitoring of TT's Cafe. This had the potential to negatively impact all inpatients, staff and visitors on 4/22/2013, 4/23/2013 and 4/24/2103. (A0619)

Based on observations, interviews and record reviews, the facility did not provide to the patients a substitute of equal nutritional value during noon mealtime on 4/22/2013, for the following individuals: Pt 1, Pt 2, Pt 4 and Pt 6. negatively impacting 4 out of 10 patients on children ' s unit-53B. (A-0628)

Based on observations, interviews, record reviews (refer to A0622), the facility did not ensure that food and dietetic services organization requirements are met. This could potentially affect all 78 patients receiving treatment at this facility.

Findings include:

On 4/23/2013, 8:48 AM - 9:04 AM, during interview of Dietary Supervisor G (DS-G), it was stated that there were not any other areas preparing food other than the off-site main foodservice area.

On 4/24/2013, 11:40 AM, was informed there was a snack shop in the hospital that serves outpatients. DS-G states hasn't anything to do with it.

Based on observation and staff interviews, the hospital did not assure that dietary staff were competent in their duties as portrayed by the cleanliness and appropriateness of staff appearance; the cleanliness and condition of food storage and other food areas; and the general practices of food service to patients. Areas surveyed included offsite kitchen that services hospital patients and an onsite cafe that patients and outpatients can access. The totality of these issues has the potential to negatively impact on all in patients on 4/22/13, 4/23/13, 4/24/13.

Findings include:

Food Service area, known as TT, located in hospital, was operating as a restaurant, without a license and storing, preparing and serving food in an unsafe manner ultimately putting patients/families/visitors at risk for foodborne illness. On 4/25/2013, referral was made to Wisconsin's Department of Public Health and TT's Cafe was closed down. For additional findings regarding this cafe area, refer to A084 and A085

The main off-site foodservice area and/or hospital ' s second floor dietary tray-line area had the following issues:
* Staff with hair not being appropriately restrained, including facial hair.
* Hands re-contaminated after washing
* Outdated/unlabeled food items
* Equipment and utensils dirty with food residue and other debris.

Findings for off-site main food service area and hospital's second floor dietary tray-line area are as follows:

HAIR RESTRAINTS
Dietary Supervisor-G (DS-G) stated the 2009 Food and Drug Administration (FDA) Food Code is the professional standard of practice for facility's foodservice areas. The 2009 FDA Food Code states hair needs to be properly restrained to prevent hair coming into contact with food, clean equipment, utensils, linens and unwrapped single-service and single-use articles.

On 4/22/2013, 1:44 PM - 3:30 PM, in the off-site main kitchen, the following observations were made regarding improperly restrained hair and facial hair and confirmed by DS-G: Engineer F - head hair and mustache not covered; Food Service Supervisor H (FSS-H) - hair falling out of hair restraint; FSS I - beard and mustache were not covered; Dietary Aide J (DA-J) - Back of head on left side a large chunk of hair not covered; DA-K - Facial hair and mustache were not covered.

On 4/23/2013, 10:40 AM - 11:10 AM, in the second floor dietary tray-line area, the following observations regarding improperly restrained hair and facial hair were made and brought to the attention of each staff person with hair inappropriately covered or not covered at all: FSS-PP, large amount of hair falling out of hair restraint; DA-BB - mustache not covered; FSS-PP - hair falling out of restraint; Occupational Therapist FF in dietary and walk-in cooler without any hair restraint; DA-GG-mustache not covered.

On 4/24/2013, 2:23 PM RDM-QQ provided an information sheet each employee receives titled "PERSONAL HYGIENE" "Employee to take home and review." Under section "Hair Restraints," it states "Wear a hair restraint, net, or hat to keep your hair out of food. If you have a beard, you may need a beard restraint as well."

On 4/24/2013, 2:27 PM, Resident District Manager-QQ (RDM-QQ) verified staff is to have hair and facial hair properly restrained. Review of "PRE-TRAY LINE MEETING," 4/24/2013, states that beard guards must be worn by all employees that have any facial hair.

HAND HYGIENE
Dietary Supervisor-G (DS-G) stated the 2009 Food and Drug Administration (FDA) Food Code is the professional standard of practice for facility's foodservice areas. According to the 2009 FDA Food Code, food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles. Hands are to be washed to remove soil and contamination.

On 4/23/2013, 10:40 AM - 11:10 AM, in the second floor dietary tray-line area, the following observations were made regarding the recontamination of hands by turning off faucet with bare hands after washing them. Each observation was validated by staff person who was in noncompliance of proper handwashing and by DS-G and FSS-PP: DA-CC, DA-DD and DA-EE.

On 4/24/2013, 2:23 PM RDM-QQ provided an information sheet each employee receives titled "PERSONAL HYGIENE" "Employee to take home and review." Under section "Hand Washing," "How" , it states "Turn off running water with a paper towel, NOT with bare hands."

On 4/24/2013, 2:27 PM, RDM-QQ provided "PRE-TRAY LINE MEETING," 4/24/2013, states under "Proper hand washing," "turn tap off with towel."

FOOD STORAGE
Dietary Supervisor-G (DS-G) stated the 2009 Food and Drug Administration (FDA) Food Code is the professional standard of practice for facility's foodservice areas. According to the Food and Drug Administration and the United States Department of Agriculture, Food Safety and Inspection Service (USDA, FSIS) storage of food must be done in a manner to prevent foodborne illnesses caused by harmful pathogens and to preserve the quality and nutritional value of food. Based on observations, interviews and record reviews, the facility failed to store food in a safe manner. Findings are as follows:

4/22/13, at the off-site main food service's food storage areas, the following observations were made and validated by DS-G:

2:15 PM, urn cleaner was stored in same cabinet as spices
2:16 PM, soiled apron found in gray container on top shelf of 5 shelf cart next to spice cabinet.
2:19 PM, individual container of Thick & Easy, Honey Consistency apple juice with use by date of Jan.17, 2013
2:23 PM, 3 packets of undated pudding mixes - Lemon, Butterscotch and Pistachio
2:42 PM, mop and pail containing dirty water stored in snack and nourishment area
2:46 PM, no internal thermometer inside nourishment cooler
2:47 PM, walk-in cooler, #2 had pans of cookies without any label/date. Container of cookie dough did not have a date.
2:50 PM, milk cooler did not have an internal thermometer
2:52 PM, walk-in freezer did not have an internal thermometer. Mixed vegetables and chocolate chip cookies were not covered properly.

4/24/13, 4:00 PM - 4:30 PM, review of undated policy/procedure, "STORAGE OF FOOD," states the following: In the section, "Storage Upon Receiving" , it states: "Place chemicals and supplies in appropriate storage areas, away from food" ; " Make sure all goods are dated with receiving date and use-by-date, as appropriate." In the section, "Temperature Control", it states "Every refrigerator and freezer must be equipped with an internal thermometer, even if equipped with an external thermometer."

EQUIPMENT AND UTENSILS
Dietary Supervisor-G (DS-G) stated the 2009 Food and Drug Administration (FDA) Food Code is the professional standard of practice for facility's foodservice areas. According to the 2009 FDA Food Code, equipment and utensils shall be kept free of an accumulation of dust, dirt, food residue and other debris. Based on observation, interview and record review, the facility failed to store equipment correctly and to assure that all equipment and utensils are free from an accumulation of dust, dirt, food residue and other debris.

On 4/22/13, at the off-site main food service area, with DS-G present, the following observations were made and verified:

2:28 PM, disposable round black plastic platters and plastic domes open and exposed to dust/dirt
2:36 PM, coffee filters, dirty and dusty with dead bug inside
2:45 PM, clean sheet pans stored right side up
2:56 PM, motor control area for rotating oven was open to the kitchen. Inside on the motor and its components was very, very thick, dusty hanging gray dirt.
2:59 PM, slicer, which was covered and not in use, had areas of debris on the blade and surrounding area. DS-G stated would say that it's meat, but doesn't know for sure.
3:03 PM, large floor mixer, which was covered and not in use, had couple spots of dried substance in area where paddles connect.

On 4/24/13, 4:00 PM - 4:30 PM, review of un-dated policy/procedure, "GENERAL INFECTION CONTROL IN THE FOOD SERVICE DEPARTMENT" , bullet 5, states "All equipment, utensils, counters, tables, drawers, and shelves will be maintained in a clean condition at all times ... "

Based on observations, interviews and record reviews, the facility did not provide to the patients a substitute of equal nutritional value during mealtime for the following individuals: Pt 1, Pt 2, Pt 3, Pt 4 and Pt 6. negatively impacting 5 out of 10 patients on children's unit-53B.

On 4/22/13, 11:28 AM, unit-53B, food cart arrived in activity room on children's unit. Menu was sausage pizza, lettuce salad, baked breadstick, canned fruit and gingerbread/orange cake. The substitute was a baked beef patty, grilled cheese sandwich or cold cut sandwich. CNA L delivered trays of food to all patients on unit-53B. At 11:30 AM, Pt 6 stated doesn't want burger because there isn't a bun. Pt 6 was then given pizza from Pt 1 who stated did not want the pizza. During interview of CNA L, on 4/24/2013, 10:48 AM, CNA L stated did not see Pt 1 give away pizza and patients are not to trade food.

On 4/22/13, 11:37 AM, unit-53B , Pt 2 put entire tray back onto cart without eating anything, stating the pizza is nasty. While Pt 2 was walking away, CNA L offered a "sandwich," but didn't say what type of sandwich or what other substitutes were available. No additional efforts were made to determine a substitute food item. On 4/24/13, 10:37 AM, RN HH and RN II were not aware of Pt 2 not eating his meal.

On 4/22/13, 11:40 AM, unit-53B ,Pt #3 wanted another breadstick. CNA L stated cannot have another bread stick-states can only have one. CNA L did offer another one when returned to room. On 4/22/13, 10:48 AM, during interview, CNA L stated only enough is provided on the tray. The only time there is extra is if someone's been discharged, then if there is anything left over, can provide extra. CNA L also stated cannot give more because then others would want more.

On 4/22/13, 11: 41 AM, unit-53B, Pt 4 didn't eat the pizza. No staff noticed or offered a substitute.

On 4/22/13, 11:41 AM, unit-53B , Pt 6 put milk back, stating does not like milk. No substitute was offered. CNA L, on 4/24/13, at 10:48 AM reported did not know Pt 6 did not drink milk.

On 4/22/13, 11:46 AM, unit-53B, interviews regarding the food provided revealed the following: Pt 4, pizza was nasty and Pt 6 stated food is "terrible, terrible." Pt 6 asked if the white dots were cheese. During interview on 4/24/13, 10:48 AM, CNA L validated that no one liked the pizza and those that received the burger were wondering where the bun was. Also stated children don't eat most of the food provided. On 4/24/13, 11:03 AM, RN-HH stated the food provided to the children has been a "frustration of ours." "It's not kid friendly."

On 4/24/2013, 11:21 AM, RD-AA stated does not do meal rounds and would not know if someone isn't eating unless flagged or reported by the nurses.

On 4/24/2013, Interim Director of Nursing-D (IDN-D) provided a survey, CAIS Youth Survey, Annual Report, 2012 which collects demographic data in addition to obtaining opinions about the services. The question "What would you improve about the program here?" 48% responded the food.

A standard Recertification Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 04/22/2013 through 4/25/2013. The Milwaukee County Behavioral Health Division (facility) was found to be NOT in compliance with the following applicable regulations for hospital participation in Medicare-Medicaid:

42 CFR 482.41 Condition of Participation: Physical Environment was NOT MET

The facility was surveyed under the 2000 Life Safety Code, Chapter 19 for an Existing Health Care Occupancy (Hospital) and Chapter 39 for an Existing Business Occupancy (Food Services Bldg.).

FINDINGS INCLUDED: Twenty-two (22) federal deficiencies of the Life Safety Code were cited as follows:

K-18 (corridor doors),
K-22 (exit signs),
K-27 (smoke barrier doors),
K-29 (hazardous spaces),
K-33 (stairs continuous fire-rating),
K-34 (exit stairway),
K-36 (dead-end corridor),
K-38 (egress access),
K-39 (clear & unobstructed width),
K-45 (general means of illumination - dbl. bulbs),
K-46 (emergency lighting),
K-48 (fire evacuation),
K-51 (fire alarm & detection),
K-54 (smoke detector maintenance),
K-62 (sprinkler system maintenance),
K-64 (portable fire extinguisher maintenance),
K-67 (heating & ventilating system maintenance),
K-69 (fire protection of commercial cooking operations),
K-75 (trash collection receptacles >32 gal.),
K-76 (medical gas storage),
K-103 (limited combustible partitions),
K-147 (electrical wiring).

(please see the individual K-tags for further detail)
_________________________

Based on observation, staff interviews and review of maintenance records, the facility including Buildings #3 & Building #4 did not maintain the condition of the physical plant and overall hospital environment in a manner to ensure the safety and well-being of patients. The facility did not have ceilings free of damage, handrails or counters free of damage, floors free of damage, a complete maintenance inspection program, and walls free of damage. This deficiency had the potential to affect all patients, staff and visitors within 5 of the 22 smoke compartments.

FINDINGS INCLUDE:

1. On 02/22/2013 at 2:49 pm, observation revealed on the 1st Floor floor of Building #4, in the Clean Food Storage area next to Food Production, that a portion of the ceiling was damaged and in need of repair. The ceiling was observed to have 2 full ceiling tiles stained due to moisture coming through floor above and one light fixture lens stained from moisture above. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). This observed situation was not compliant with 42 CFR 482.41(a).

2. On 02/22/2013 at 2:51 pm, observation revealed on the 1st Floor floor of Building #4, in the Storeroom #5 next to Cooking area, that a portion of the ceiling was damaged and in need of repair. Ceiling tiles were stained a yellow-brown color from moisture coming from above. The room was being used for clean carts used in the holding of clean and sanitary food products. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). This observed situation was not compliant with 42 CFR 482.41(a).

3. On 02/22/2013 at 2:55 pm, observation revealed on the 1st Floor floor of Building #4, in the Food Cooking area, that a portion of the ceiling was damaged and in need of repair. Two ceiling tiles above the Baxter 'Oven' (this is a large commercial rotating shelves oven) were open and collapsing onto the Oven top. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). This observed situation was not compliant with 42 CFR 482.41(a).

4. On 02/23/2013 at 4:46 pm, observation revealed on the Wing area 5/ Level 3-B floor of Building #3, in the Corridor near Stairwell 5-5, that a portion of the 'handrail' was damaged and in need of repair. The handrail was observed without the turned-in cap to wall required by Code. And based on the unique patient population, the handrails must be provided with a closure plate near its bottom, to prevent any item passing through the handrail that could be used by the patient (in a negative way) to hurt themselves. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). This damage renders this 'handrail' dangerous to the patient population. This observed situation was not compliant with 42 CFR 482.41(a).

5. On 02/22/2013 at 2:00 pm, observation revealed on the 1st Floor floor of Building #4, in the Outside the Food Prep Area, that a portion of the flooring was damaged and in need of repair. The ceramic tile was damaged and not maintained in a food production area in front of the 2-compartment sink. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). This damage renders this surface porous and non-cleanable. This observed situation was not compliant with 42 CFR 482.41(a).

6. On 02/22/2013 at 3:15 pm, observation revealed on the 1st Floor floor of Building #4, in the area of the Cooking Hood, that a portion of the flooring was damaged and in need of repair. The raised stoop previously used to support a cooking piece of equipment, was removed since 2010 and the exposed surface was not properly covered in a sanitary and clean environment. The exposed concrete was porous and not properly sealed in the cooking area. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). This damage renders this surface porous and non-cleanable. This observed situation was not compliant with 42 CFR 482.41(a).

7. On 02/24/2013 at 11:05 am, observation revealed on the Wing area 5/ Level 3-A floor of Building #3, in the Art Storage Room 3322-4A, that a portion of the flooring was damaged and in need of repair. The tile base cove was cracked and damaged. No work orders were provided to show it was on the maintenance repair list to correct this damage. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). This damage renders this surface porous and non-cleanable. This observed situation was not compliant with 42 CFR 482.41(a).

8. On 02/24/2013 at 4:01 pm, observation revealed on the Wing area 4/ Level 3-B floor of Building #3, in the Stairwell 4-3, that during a review of maintenance documents the facility did not implement and follow a routine preventive maintenance and testing program. Observations of the exterior door at Stairwell 4-3 revealed the door would not close and latch. The door was warped and would not fully-close to the frame. In checking the preventive maintenance (pm) list, this door was not on the list at the time of the survey. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). This observed situation was not compliant with 42 CFR 482.41(a).

9. On 02/25/2013 at 1:03 pm, observation revealed on the Wing area 4/ Level 2-A floor of Building #3, in the Dental Clinic, that during a review of maintenance documents the facility did not implement and follow a routine preventive maintenance and testing program. During the survey tour, it was observed that the Dental Clinic has abandoned the medical gas piping for the Nitrous Oxide and Oxygen Gas lines. Existing 'life safety' features obvious to the public, if not required, shall be either: 'maintained or removed'. This observed situation was not fully compliant with NFPA 101 section 4.6.12.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). This observed situation was not compliant with 42 CFR 482.41(a).

10. On 02/22/2013 at 2:08 pm, observation revealed on the 1st Floor floor of Building #4, in the Cold Preparation Room, that a portion of a wall was damaged and in need of repair. The door frame attached to the wall was damaged about 12 inches above the floor, caused by a significant impact. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). This damage renders this surface porous and non-cleanable. This observed situation was not compliant with 42 CFR 482.41(a).

11. On 02/22/2013 at 3:00 pm, observation revealed on the 1st Floor floor of Building #4, in the Food Cooking area, that a portion of a wall was damaged and in need of repair. The walls next to the 9 steel kettles, used for cooking and food preparation, were not sealed per the requirements for a clean and sanitary environment. The 2 steam pipes per kettle, were protruding and had exposed space around the pipes. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).

12. On 02/22/2013 at 2:10 pm, observation revealed on the 1st Floor floor in the Food Services Building at the Production Kitchen to the Loading Dock, that the corridor door would not positively self-latch. The fire-rated door was equipped with a closer, but it would not hold the door in the latched position. Wood wedges were observed under the doors to prevent them from closing. The doors being propped-open also could cause an air imbalance. The air from the dirty Loading Dock area could compromise the clean air on the sanitary Food Production side per 42 CFR 482.41 Environment Condition. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).
____________________________________


15410


1. Observation on 04/22/13 included a tour of the 5-3B Adolescent Inpatient Unit from 10:55 a.m. to 12:05 p.m. and 2:25 p.m. to 3:25 p.m. accompanied by Nursing Program Coordinator (NPC) M.

Observation at 11:00 a.m. identified Room #1 with a double paned window to the outside. The window ledge on the left was open to the 2 patients who currently lived in the room and was noted to have a moderate amount of white and gray debris.

Observation at 11:25 a.m. identified Room #3305-10, the patient's laundry room, to have an area between the washing machine and a cupboard on the right with an area of cracks over approximately 9 to 10 inches just above the floor/wall trim.

Observation at 2:50 p.m. identified Room #38 with a double paned window to the outside. The window ledge on 1 side was open to the 1 patient who currently lived in the room and was noted to have a moderate amount of white and gray debris.

Based on record review and staff interview, the facility did not provide an emergency water supply. This deficiency had the potential to affect all patients, staff and visitors in 22 of the 22 smoke compartments.

FINDINGS INCLUDE:

On 02/23/2013 at 3:45 pm, record review of the maintenance documents indicated the facility did not provide documentation to show they have a comprehensive system to provide for the quantity of emergency (water) that would be needed to provide care to patients. The reviewed documents did not include provisions to:

(a) protect these limited emergency supplies,
(b) prioritize their use until adequate supplies are available,
(c) address the event of a disruption in supply (e.g., disruption to the entire surrounding community),
(d) determine the quantity of supply readily available at the hospital,
(e) determine the quantity needed within a short time through additional deliveries.

The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer). This damage renders this surface porous and non-cleanable. This observed situation was not compliant with 42 CFR 482.41(a)(2).

A standard Recertification Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 04/22/2013 through 4/25/2013. The Milwaukee County Behavioral Health Division (facility) was found to be NOT in compliance with the following applicable regulations for hospital participation in Medicare-Medicaid:

42 CFR 482.41(b) Standard: Safety from Fire was NOT MET.

The facility was surveyed under the 2000 Life Safety Code, Chapter 19 for an Existing Health Care Occupancy (Hospital) and Chapter 39 for an Existing Business Occupancy (Food Services Bldg.).

FINDINGS INCLUDED: Twenty two (22) federal deficiencies of the Life Safety Code were cited as follows:

K-18 (corridor doors),
K-22 (exit signs),
K-27 (smoke barrier doors),
K-29 (hazardous spaces),
K-33 (stairs continuous fire-rating),
K-34 (exit stairway),
K-36 (dead-end corridor),
K-38 (egress access),
K-39 (clear & unobstructed width),
K-45 (general means of illumination - dbl. bulbs),
K-46 (emergency lighting),
K-48 (fire evacuation),
K-51(fire alarm & detection),
K-54 (smoke detector maintenance),
K-62 (sprinkler system maintenance),
K-64 (portable fire extinguisher maintenance),
K-67 (heating & ventilating system maintenance),
K-69 (fire protection of commercial cooking operations),
K-75 (trash collection receptacles >32 gal.),
K-76 (medical gas storage),
K-103 (limited combustible partitions),
K-147 (electrical wiring).

(please see the individual K-tags for further detail)
_________________________

Based on observation and interview the hospital staff failed to ensure that necessary items and equipment were clean and in good repair, and that sterile supplies were not expired. This had the potential to affect all 78 hospital patients present during the survey.

Findings include:

Observation on 4/22/13 included a tour of the 5-3B Adolescent Inpatient Unit from 10:55 a.m. to 12:05 p.m. and 2:25 p.m. to 3:25 p.m. accompanied by Nursing Program Coordinator (NPC) M.

Observation at 11:18 a.m. identified a soiled utility room (near Rooms 3305-8 and 3305-10) with a paper towel holder secured on the wall having a layer of visible dust on its top ledge. During an interview at the time, NPC M stated the hospital utilized a contracted service called "UU" for cleaning.

Observation at 11:34 a.m. identified in Room 3305-15 (patient exam room) an area of visible dust and debris at the foot-end of the exam table just above 2 drawers built into the table. Observation at that time, in the same room, also identified a soap dispenser secured to the wall above the sink with a type of masking tape encircling the entire circumference of the unit. On multiple attempts when attempting to utilize the dispenser to obtain soap, the dispenser came apart from where it was taped, part of it falling forward making the unit unable to function properly.

Observation at 11:40 a.m. identified in Room 3305-19 several items of equipment including a crash cart that was covered with a cloth covering. NPC M removed the cover and a suction machine was noted with a moderate amount of visible dust.

Observation at 11:55 a.m. identified in Room 3305-19, upper and lower cabinets/drawers (all numbered) along 2 walls of the room. In drawer #12 were noted 6 "sterile" packages of "BBL" culture swabs, all with expiration dates of 2013/01 (expired.) NPC M stated the culture swabs should have been replaced and promptly removed the expired culture swabs from the drawer.

Observation at 2:40 p.m. identified in Room 35, where 2 patients currently resided, one of the beds (on the left upon entering the room) with a wooden bedframe that was cracked and broken. The cracked/broken area measured approximately 2 to 3 inches by 10 to 12 inches and the particle board underneath the finish was exposed and rough, making it uncleanable. It was also noted that the wardrobe unit in the room had an area on the bottom shelf approximately 1 to 3 inches in a triangular pattern where the finish was worn away exposing particle board (rough in places) underneath, making the area uncleanable.

Observation at 2:50 p.m. identified in Room 38, where 1 patient currently resided, the wardrobe unit in the room had gouges on the right (irregularly-shaped_ and left (nickel-sized) front panels exposing the underlying wood, making the areas uncleanable.

Observation at 3:00 p.m. identified, in a room next to room 35, a kitchenette area for patients and staff, an area beneath the sink that had a large uncleanable area with paint chipping and bubbling. There was nothing stored in the area at that time. The kitchenette area also included a microwave that was soiled with visible residue on the inside of the door and on the entire inside. NPC M stated the microwave was normally for staff use.

Observation at 3:12 p.m. identified in room 3305-23 a "Pyxis" medication-return bin securely attached to the wall. The top of the unit was noted to have a moderate to large amount of dust. NPC M cleaned the unit at that time.

Observation on 04/23/13 at 8:15 a.m. on unit 5-3B in the Day Room/Dining Room identified a table next to the windows facing the nurses' station which had 1 of the 4 corners chipped, exposing the wood underneath, making it uncleanable.