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Based on clinical record review and interview, it was determined the facility failed to assure four (#1, #2, #3 and #4) of six (#1-4, #13 and #15) Medicare beneficiaries were provided "An Important Message from Medicare" within two days of admission. Without receiving the Important Message from Medicare notice, it could not be assured that the patients and/or their Representatives had the information necessary to make informed decisions regarding their rights as a Medicare Beneficiary. The failed practice had the potential to affect all Medicare Beneficiary recipients who received care at the facility. Findings follow:

A. Review of clinical records on 08/30/11 at 1500 revealed four (#1, #2, #3, and #4) of six (#1-4, #13 and #15) Medicare Beneficiaries clinical records lacked acknowledgement of receipt of the notice of Important Message from Medicare.
B. Interview with the Interim Regulatory Officer on 08/31/11 at 1300 confirmed the above findings.

Based on observation, policy review and interview, it was determined the facility failed to assure the equipment was maintained in good condition. Failure to assure equipment was maintained in good condition had the potential to compromise patient safety. The failed practice had the potential to affect all patients admitted to the Behavioral Health Unit. Findings follow:

A. Observation of the Behavioral Health Unit was conducted with the Nurse Manager and the Behavior Health Administrator on 08/30/11 at 0945-1100. The following was observed:

1) Patient Exam Room table mattress had a 1 1/2 (inch) tear which exposed the foam.
2) The Nourishment Room wall cabinet's interior and exterior surfaces as well as the walls contained multiple stains of unknown substance.
3) The 3rd patient shower from nurse's station contained a bed side table with a chipped top exposing the wood underneath and the wooden bench in the shower contained a buildup of rust at the metal base where the bench was bolted to the shower floor.
4) The West seclusion room had signage which stated Day Room Group A. Inside the seclusion room the walls contained areas with the sheet rock exposed, tears in the wall paper and stained walls.
5) The bathroom in Patient Room 8080 contained a softball sized hole in the bathroom wall adjacent to the toilet. The hole was stuffed with tissue; the patient in the room stated "I stuffed the hole with tissue so a rat won't come in."
6) Patient Room 8085 revealed a bathroom that contained missing wall tiles behind the toilet.
7) The East Day Room contained two fabric chairs with multiple torn areas exposing the padding which cannot be cleaned.
B. All of the above findings were confirmed during the tour with the Nurse Manager.