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110 REHILL AVE

SOMERVILLE, NJ 08876

GOVERNING BODY

Tag No.: A0043

Repeat Deficiency

Based on document review, interview, and observation, it was determined that the Governing Body failed to demonstrate it is effective in carrying out the responsibilities for the operation and management of the hospital. The Governing Body failed to provide necessary oversight and leadership as evidenced by the lack of compliance with the following Conditions of Participation:

CFR 482.13 Patient's Rights

PATIENT RIGHTS

Tag No.: A0115

Repeat Deficiency

Based on observation, medical record review and staff interview, it was determined that the facility failed to protect and promote the rights of each patient.

Findings include:

1. The facility failed to ensure that patient's are provided care in a safe setting. Refer to Tag A-0144.

PATIENT RIGHTS: CARE IN SAFE SETTING

Tag No.: A0144

20148

Repeat Deficiency

Based on staff interview and observations made during a tour of the 5 West unit, it was determined that the facility failed to ensure that the psychiatric unit was compliant with suicide prevention regulations.

Findings include:

1. At approximately 10:00 AM on 4/11/13, the 5 West unit was toured in the presence of Staff #2. The following observations were made:

a. The patient bedrooms (Rooms #587, #588, #589, #590, #591, #592, #593, #594, and #595 [the quiet room] were all noted to have a bathroom within the room. Each bathroom had a sink equipped with a faucet which could support the weight of an individual in a suicide attempt.

b. Staff #2 confirmed the above findings.



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