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The Governing Body failed to demonstrate that it is effective in carrying out the operation and management of the facility. The Governing Body failed to provide necessary oversight and leadership as evidenced by the lack of compliance with the following Condition of Participation:

482.41 Physical Environment

Based on a review of policy and procedure, observation, and interview with administrative and direct care staff, it was determined that the facility failed to ensure that the Patient's Bill of Rights is met.

Findings include:

Reference #1: Policy titled SENDING AND RECEIVING MAIL stated:
"I. POLICY
A. Statement
Patients shall be permitted to send and receive unopened mail as well as have ready access to letter writing materials in accordance with "The Patients Bill of Rights. "N.J.S.A. 30:4-24. 1 et seq.
II. PROCEDURE
.....
C. Patients may personally drop their outgoing mail in the hospital mail room or place it with their Complex's outgoing mail. Postage will be affixed by the mail room staff as needed.
....."

Reference #2: The Trenton Psychiatric Hospital PATIENTS' BILL OF RIGHTS: stated:
.....
9. To keep and use your personal possessions.
.....
14. To have ready access to letter writing materials, including stamps, and to mail and receive uncensored correspondence.
....."

1. An envelope with the name of Patient #33 and the words "Apt (Apartment) Key" written on it in was found in the Medication Room of the Kennedy Unit during a tour on 7/12/16. Administrator #7 stated that the patient was no longer being cared for on the Unit. The facility failed to return the key to the patient prior to transferring or discharging him/her.

2. A pair of glasses with the name of Patient #34 on them was found in the Medication Room of the Lazarus Unit during a tour on 7/12/16. Administrator #7 stated that the patient had been transferred to another area of the hospital. The facility failed to ensure that the glasses were transferred with the patient.

3. A drawer in the Nurses Station of Raycroft East One Unit contained a paper bag with the name of Patient #26 and the word "Contraband" written on during a tour on 7/13/16. The bag contained three (3) pairs of sunglasses, shave gel, a leather wrist band, an envelope with a greeting card, one (1) pair of glasses, and a box with an earring inside of it. Another bag with the same patient's name on it containing condoms was in the same drawer. Review of the Unit Roster indicated that the patient was no longer being cared for on the Unit.

4. A drawer in the Nurses Station of the Raycroft East Two Unit contained an envelope with the name and medical record number of Patient #26 written on it during a tour on 7/13/16. Review of the Unit Roster indicated that the patient was no longer being cared for on the Unit.

5. A drawer in the Nurses Station of the Raycroft West Two Unit contained a sealed envelope with the name of Patient #27 and the hospital address as the return address during a tour on 7/13/16. The letter was addressed to someone with the same surname as Patient #27. It could not be determined how long the letter had been in the drawer. The Nurse Manager of the Unit, Staff #40, stated that the drawer was not the place where the Unit's outgoing mail was to be kept. Facility policy regarding outgoing patient mail was not followed.

6. A tour of the Nurses Station in Drake West One Unit on 7/14/16 revealed:

a. A paper bag of personal belongings with the name of Patient #35 was found in the bottom drawer under the counter. Administrator #4 stated that the patient had been transferred to a Cottage on the hospital grounds.

b. A bracelet in a paper bag with the name of Patient #36 on it was found in the bottom drawer under the counter. Administrator #4 stated that the patient was no longer being cared for on the Unit.

c. Two envelopes of personal belongings with the name of Patient #37 were found in the bottom drawer under the counter. Administrator #4 stated that the patient had been transferred to another unit.

d. Books and a cloth bag in a paper bag with the name of Patient #38 on it were found in the bottom drawer under the counter. Administrator #4 stated that the patient had been transferred to a Cottage on the hospital grounds.

7. A bag of clothing, including a pair of sneakers, with the name of Patient #30 on it was found in a cabinet in the Visitor's Room of the Drake West Two Unit on 7/15/16. Administrator #41, a Unit Charge Nurse, stated that the patient had been "discharged a couple of weeks ago." He/She further stated that the patient's mother had called the Unit to complain that the sneakers had not been returned to the patient upon discharge. The Charge Nurse stated that he/she found the sneakers and called the patient's mother back, but as of the date of the tour no one had come to pick up the sneakers.

A. Based on review of policy and procedure and observation, it was determined that the facility had policies regarding environmental safety that were not implemented.

Findings include:

Reference #1: Facility policy titled SEARCH AND REMOVAL OF CONTRABAND IN THE ENVIRONMENT OF CARE stated:
"I. SCOPE OF POLICY
A. AUTHORITY
Under the authority of the Chief Executive Officer and senior leadership of the Cabinet, all administrative, support, and clerical staff will assure that contraband and potentially dangerous objects will be identified and removed from the hospital environment.
.....
II. DEFINITIONS
A. CONTRABAND
Contraband is defined as any item/object that may threaten the health, safety, and/or security of patients or others in the hospital setting. For all patients, visitors, and staff, contraband includes the following when it is accessible to patients of the facility:
.....
10. Hooded sweatshirts and sweat pants that have drawstrings - (Only allowed in Travers Complex)
....."

1. During a tour of the Kennedy Unit, two pairs of sweat pants with drawstrings in them were observed in a patient's clothes closet in Room B-105.

Reference #2: The "Procedure" section of EMERGENCY EQUIPMENT & TREATMENT ROOM CHECK forms stated:
"* At every change of shift (6:45 AM, 2:45 PM, & 11:00 PM), the charge nurse will assess the Emergency Equipment and note the appropriate response with a check mark in the appropriate box, (Y) for YES or (N) for NO and sign his/her name.
....."

1. The EMERGENCY EQUIPMENT & TREATMENT ROOM CHECK forms for the month of June 2016 for the Drake W2 Unit did not include entries indicating that the equipment was checked on the 11-7 Shift on 6/20/16; the 3-11 Shift on 6/25/16; the 3-11 and 11-7 Shift (incomplete entries) on 6/26/16; and the 3-11 Shift on 6/27/16.

2. The EMERGENCY EQUIPMENT & TREATMENT ROOM CHECK forms for the month of June 2016 for the Kennedy Unit did not include entries indicating that the equipment was checked on the 11-7 Shift on 5/31/16; the 7-3 Shift on 6/3/16; the 3-11 or 11-7 Shifts on 7/1/16; the 7-3 Shift on 7/11/16; or the 3-11 Shift on 7/12/16.

Reference #3: The instructions at the bottom of TEMPERATURE RECORD FOR REFRIGERATOR/FREEZER forms stated: "Record Medication, Food Refrigerator and Freezer temperatures at the start of each shift. ....."

1. The TEMPERATURE RECORD FOR REFRIGERATOR/FREEZER form for the month of July 2016 regarding the pantry refrigerator on the Kennedy Unit did not indicate that the temperature was checked during the 7-3 Shift on 7/1/16, 7/2/16, 7/3/16, or 7/4/16; that the thermometer was broken during all three shifts on 7/6/16; and that the thermometer was broken during all three shifts on 7/10/16, 7/11/16, or the first two shifts on 7/12/16. A tour of the Unit on the afternoon of 7/12/16 indicated that the thermometer was broken.

2. The TEMPERATURE RECORD FOR REFRIGERATOR/FREEZER form for the month of July 2016 regarding the pantry refrigerator on the King Unit did not indicate that the temperature was checked during the 3-11 Shift on 7/1/16, 7/2/16, 7/3/16, 7/4/16, or 7/5/16; that the temperature was checked during the 11-7 or 3-11 Shifts on 7/7/16 and 7/8/16; that the temperature was checked during the 11-7 Shift on 7/9/16 or 7/10/16; that the temperature was checked during the 3/11/16 Shift on 7/11/16; or that the temperature was checked during the 11-7 Shift on 7/12/16.


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B. Based on a tour of the facility, it was determined the facility failed to ensure that a safe and sanitary environment is maintained for all patients.

Findings include:

1. A tour of the Travers Complex was conducted on 7/12/16 and revealed the following:

a. Cottage #1 had a black mold like substance in the shower.

b. Cottage #2 had a black mold like substance in the bathroom around the bathtub. The floors in the dining room appeared dirty and the baseboard had dust on the top of it.

c. Cottage #3 had a black mold like substance in the bathroom around the bathtub. A rug in the entrance way, inside the front door, had the corners of the rug turned causing a trip hazard.

d. Cottage #4 had a black mold like substance in the bathroom around the bathtub.

e. Cottage #5 had a black mold like substance in the bathroom around the bathtub.

f. Cottage #6 had a black mold like substance in the bathroom around the bathtub. A rug in the entrance way, inside the front door, had the corners of the rug turned causing a trip hazard.

g. Cottage #7 had a black mold like substance in the bathtub. The floors in the dining room appeared dirty.

h. Cottage #12 had a black mold like substance in the bathroom around the bathtub. Cottage #12 also had bare plywood on the upstairs floors in all bedrooms.

2. A tour of the Raycroft Building basement was conducted on 7/14/16 and revealed the following:

a. The tiles in the basement patient physical therapy area were cracked and chipped. There were marks on the floor that were rust colored.

b. The sink in the GYN/Ortho clinic had a crack that ran from the faucets to the drain.

c. The sink in the clinic area where EKG's are performed had an area of what appeared to be spilled soap and hand sanitizer underneath. Above the sink there were holes in the wallboard.

3. A tour of the Raycroft Building dining area between West-1 and East-1, on the first floor, was conducted on 7/14/16 and revealed the following:

a. The heating unit cover had a rust color substance and the wallboard around the cover had pieces of wallboard missing.

b. The temperature in the food service area where the milk, juice and yogurt was stored for serving the patients at meal time ranged from 60 degrees to 63 degrees. According to the National Food Safety Database, milk should be stored at 35 degrees to 40 degrees. There was no thermometer in this food service area. Temperatures were taken by the maintenance person.

4. On 7/14/16 at 1:40 PM, the facility was toured and the following was observed:

a. In the Raycroft Basement:

(i) A ceiling tile in the hallway, near the back door had brown discoloration and was sagging.

(ii) There were several ceiling tiles that contained holes in the basement corridor near the maintenance and mechanical room doors and the elevators.

(iii) The Physical Therapy patient waiting area had brown discoloration and sagging ceiling tiles above the television.

(iv) The Vision Clinic had cracked floor tiles.

(v) The Dining room had wires hanging from the ceiling in two locations; a chipped floor tile near the door; and a wall plate with a cracked corner and hole in the wall.

(vi) On the Kitchen Service area counters, there were two (2), 2.5 gallon containers with lids, containing liquid without any labeling of contents or preparation information.

(vii) There were also four (4) brooms and one (1) dust pan sitting on the floor with the handles resting up against a sink in the food preparation area.

b. Raycroft 1 East:

(i) Room 167 had holes in the flooring.

(ii) The Quiet Room had a blue restraint chair with a torn left arm rest, exposing the wood under the material.

5. The above findings were confirmed by Staff #16 and Staff #32.


Reference #1: Facility Policy Titled "Regulated Medical Waste Management" on page 4 of 7, under Procedure A. 2., states, "Regulated Medical Waste is to be contained by using the double bag method. The double bag method consists of a paper bag which is closed when filled, then placed in a clear plastic bag; this bag is tied and then transported to the Regulated Medical Waste storage area, to be placed in the Regulated Medical Waste container, at the end of every shift."

Reference #2: Facility Procedure Titled "Isolation Procedure" on page 1 of 5, under Forms/Equipment, number 2., states, "Outside the room, Disposable gowns..."

1. A tour of the Lincoln Complex was conducted on 7/15/16 and revealed the following:

a. While touring the Lincoln unit on 7/15/16 at 10:45 AM, a patient was noted to be on isolation precautions related to having C-Diff (Clostridium difficile).

(i) The physician's order in Medical Record #32, dated 7/8/16 stated, "Keep patient 24 hour staff monitoring for isolation X 15 days."

(ii) Staff #38 was caring for the patient during the tour. He/She was questioned regarding the disposal of contaminated items from this patient. He/she stated, "When the patient has a bowel movement, his diaper is placed in a paper bag, rolled up, placed in another paper bag and the cleaning staff will take it out. If it is at night we just take it out to the dumpster."

(iii) Staff #38 failed to describe the disposal of contaminated items as indicated in Reference #1.

(iv) Staff #38 was questioned where the disposable gowns were kept and he/she stated, "Right in the drawer outside of the room." When this surveyor opened the drawer, it was empty.

(v) Staff #38 failed to ensure disposable gowns were readily available outside of the room as indicated in Reference #2 above.

(vi) Staff #16 confirmed the above findings.





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C. Based on observation, staff interviews, and review of facility documents, it was determined that the facility failed to ensure that medication is dispensed in a safe manner.

Findings include:

Reference #1: Facility Policy & Procedure Self Medication states, "... PROCEDURE:
...
B.
... b. The medication will be dispensed in a non-unit dose retail vial labeled with the patient's name, drug, and directions. ..."

Reference #2: Facility Policy & Procedure Transcription of Physician's Order states, "...
PROCEDURE
...
b. The nurse transcribes the order on the appropriate form i.e. MAR (Medication Administration Record), TAR (Treatment Administration Record), laboratory slip, etc.
...
d. Indicate an entire order was transcribed by printing name, title, date and time and signature ..."

1. On 7/12/16 at 10:15 AM, the Travers Complex was toured in the presence of Staff #8 and Staff #19. A medication storage cabinet contained patients self medication boxes. The following single dose medications were found in the patient self medication boxes, instead of non-unit dose retail vial labeled packaging as per facility policy in Reference #1.

a. In Cottage 2:

(i) Patient #13's self medication box contained a Condone 0.1 mg (milligram) tablet, and a Benztropine 1 mg tablet.

(ii) Patient #14's self medication box contained a Magnesium hydroxide/estimation/aluminum hydroxide 30 ml (milliliter) oral suspension.

(iii) Patient #15's self medication box contained one Aspirin 81 mg tablet and one Acetaminophen 500 mg tablet.

b. In Cottage 12:

(i) Patient #16's self medication box contained a Lamotrigine 150 mg tablet.

2. The above findings were confirmed by Staff #8 and Staff #19.

3. On 7/12/16, MARs were reviewed and the facility failed to transcribe all the physician medication orders onto the MAR as per the facility policy Reference #2.

a. The MAR for Patient #16 was reviewed. The Physician Medication orders, dated 6/29/16, contained the following medications: Lamotrigine 150 mg tablet twice daily at 8:00 AM and 8:00 PM, and Lamotrigine 25 mg tablet once daily at 8:00 PM (with Lamotrigine 150 mg to total 175 mg). Upon review of the MAR dated 7/1/16 through 7/12/16, it was noted that the facility failed to transcribe the order for Lamotrigine as prescribed as per facility policy.

b. Staff #20 stated during interview that Patient #16's Lamotrigine as prescribed on 6/29/16, was given as he/she was aware that the patient was on the medication, however, the medication was not documented as given on the MAR from 7/1/16 through 7/12/16.

c. All findings as noted above were reviewed and confirmed by Staff #8, Staff #20 and Staff #21.

Based on observation and interview with administrative staff, it was determined that medications are not stored in accordance with a State requirement.

Findings include:

Reference: The NEW JERSEY ADMINISTRATIVE CODE TITLE 13 LAW AND PUBLIC SAFETY CHAPTER 39 STATE BOARD OF PHARMACY stated: ".....
SUBCHAPTER 9. PHARMACEUTICAL SERVICES FOR HEALTHCARE FACILITIES .....
13:39-9.23 STORAGE AND SECURITY
a) Provisions shall be made for adequate safe storage of drugs wherever they are stored in the health care facility.
1) All drugs shall be secured for safe use and protected against illicit diversion. .....
c) Procedures shall be established to assure the immediate and efficient removal of all outdated and recalled drugs from patient care areas and from the active stock of the pharmacy. ....."

1. An unlocked metal cabinet in the Raycroft East 2 Unit Nurses Station on 7/13/16 was found to contain a plastic bag containing 274 capsules/tablets of varying types of medications. The bag was covered with paper and tape. Of the 274 capsules/tablets in the bag, 25 were outdated.

2. Administrator #4 agreed with the findings.

Based on observation, interviews with administrative staff, review of policy and procedure, and review of related documentation, it was determined that the facility failed to be constructed and maintained to ensure the safety of patients and to provide facilities appropriate to the needs of the patient community.

Findings include:

1. The facility failed to ensure the overall hospital environment was maintained for the safety and well-being of the patients, staff, and public. (Refer to Tag A-0701)

2. The facility failed to ensure adequate facilities for its services. (Refer to Tag A-0722)

3. The facility failed to maintain equipment to ensure an acceptable level of safety and quality. (Refer to Tag A-0724)

A. Based on observation, it was determined that the facility failed to ensure the overall hospital environment is maintained for the safety and well-being of the patients, staff, and public.

Findings include:

1. On 7/15/16 at 11:00 AM, in the presence of Staff #5 and Staff #7, the sanitary sewer vent located above the washing machine in the laundry room of the King Building was covered with a black substance. This substance also was present on the acoustical ceiling tiles and wood paneling wall around the vent.

2. A tour of the Lincoln Treatment Mall on 7/12/16 revealed the following:

a. In Room 153:

(i) A urinal with a dark brownish liquid in it was observed on the floor.

(ii) A restraint chair was found to have candy wrappers, cracker pieces, grit, dust, and paper scraps between the seat and back cushions and between the seat cushion the arm rests.

3. A tour of King Unit on 7/12/16 revealed the following:

a. Broken and missing floor tiles and missing pieces of floor molding in Room A-142.

b. The thermometer in the food refrigerator in the Pantry read 28 degrees Fahrenheit. The temperature log used to document the daily temperatures in the refrigerator was incomplete.

4. A tour of Kennedy Unit on 7/12/16 revealed the following:

a. A restraint chair in the Quiet Room was found to have grit, gunk, grit, dust, paper scraps, dried food particles, and half of an oblong tablet between the seat and back cushions and between the seat cushion and the arm rests. The plastic covering of one of the arm rests was ripped off in one section exposing foam and wood.

b. In the Pantry:

(i) Observed under the sink were individual maple syrup containers in a paper bag, sugar packets, unwrapped plastic spoons, bug traps, a gallon container of shampoo, and a container of mouth rinse.

(ii) The refrigerator had dust atop it and cellophane wrappers, dust, grit, a broken ballpoint pen, and mayonnaise packet beneath it.

5. A tour of Raycroft East One Unit on 7/13/16 revealed the following:

a. In the Treatment Room:

(i) An opened 12 pack of soda under the counter had tape, hair, and grit on the outside of the box.

(ii) A space behind the counter top had stained C-Fold paper towels, plastic tubing, dust, and a dirty cloth towel.

b. A restraint chair in the Quiet Room had ripped off plastic and foam on one of the arm rests exposing raw wood. Candy pieces, cracker pieces, gunk, cellophane, grit and other refuse was between the seat and back cushions, and between the seat cushion and arm rests.

6. A tour of Raycroft West One Unit on 7/13/16 revealed the following:

a. A restraint chair in the Quiet Room had a small rip in the plastic of one of the arm rests. Gunk, paper scraps, grit and other refuse was between the seat and back cushions and between the seat cushion and the arm rests.

b. Examination Room: A space behind the counter top had a stained box of Maxi-Pads, stained C-fold paper towels, dust, and other refuse.

c. Sun Porch: There was a puddle of water near the windows.

7. A tour of the Drake Complex on 7/14/16 revealed the following:

a. In the Kitchen:

(i) The sill above the stainless steel counter near the dishwasher was rusted.

(ii) There was dust on and cobwebs around the fan cover. The fan cover was also rusty.

(iii) There was rust on the sill behind the dishwasher.

(iv)The door to the Supply Room had sections of delamination.

(v) There was heavy dust on the sill behind the refrigerator.

(vi) A dried sausage patty, dust, water, grit, and gunk were observed beneath the electric steam table.

b. In the Cafeteria:

(i) There was heavy dust on the window and window ledge.

(ii) Floor tiles were cracked next to the refrigerator.

(iii) A raised purplish food substance was observed on the ceiling.

(iv) One light bulb in a recessed light was burned out.

8. A tour of Drake West One Unit on 7/14/16 revealed the following:

a. In the Nurses Station:

(i) There was delamination on the desk and a raw wood door.

(ii) The countertop had broken Formica and Formica separated from the counter.

(iii) The lock on the "Ice Packs" drawer was broken. The drawer could not be fully closed.

(iv) A drawer contained a partially used toothpaste tube, spillage, and an opened container of Aveeno moisturizing lotion.

(v) There was dust in the corner of the countertop behind binders.

b. In the Locker Area:

(i) There was a heavy accumulation of dust, gunk, cellophane, paper scraps, a sugar packet, a medication wrapper, and grit beneath two metal ceiling tiles laying next to the lockers.

(ii)Beneath the lockers was a broken wheel from a cart, an opened container of Vicks VapoRub with heavy dust and grit adhered to it, dust, grit, gunk, tissue paper, and other refuse.

(iii) A stained piece of sheetrock with exposed gypsum was leaned against an opening in the wall where telephone wires were housed. The wires were visible.

c. In the Nurses Station:

(i)Beneath a two drawer metal cabinet was a white tablet, a peanut shell, food particles, hair, a greasy substance, hair, and dust.

(ii)There were broken floor tiles beneath the emergency call box.

(iii)There was rust, grit, staples, dust, and other refuse beneath a four drawer metal cabinet.

(iv) The shelf beneath the DVD player was raw wood.

(v) A white book shelf had stains, areas of missing paint, and dust on it.

(vi)There were areas of delamination and missing paint on the sides of the desk.

d. There were multiple stained ceiling tiles in the Hallway.

e. In Patient Room W-107:

(i) There was condensation dripping from the ceiling tiles.

(ii) The bottoms of the door jambs in the bathroom were rusty.

f. In Patient Patient Room W-115 one of the three light bulbs were out.

g. In Patient Room W-106:

(i)There were six (6) broken and/or cracked floor tiles.

(ii) There was rust along the edging of the drop ceiling.

h. In Shower Room W-114:

(i) There were multiple areas of missing and peeling paint as well as cracked plaster.

(ii) Metal ceiling panels were rusty and there were areas of missing paint.

i. In Patient Room W-105 there was missing paint on one ceiling tile and one metal ceiling tile was stained.

j. There were dead bugs atop six (6) light covers in the Dayroom.

k. In Room W-109:

(i)There were dead bugs above two light covers.

(ii)The border around the access panel was raw wood.

l. In the Medication Room:

(i) The bottom section of the door on the inside of the room was delaminated.

(ii) Paint was worn off of the door jamb.

(iii) Edges of the door were delaminated in sections.

m. In the Restraint Room:

(i) A restraint bed had ripped plastic with exposed foam at the foot of the bed.

(ii) A restraint chair had paper, grit, gunk, and other refuse between the seat and back cushions and between the seat cushion and the arm rests.

n. The door of the female bathroom was raw wood.

o. There were missing pieces of molding and broken plaster in the Room W-137, the Comfort Room.

p. The floor near the Main Entrance had two (2) broken floor tiles.

9. A tour of Drake Admissions Unit on 7/14/16 revealed the following:

a. The floor behind a metal cabinet was stained. There was also dust, grit, and paper scraps behind and under the cabinet.

b. Three brown insects were observed walking around the coffee supply cabinet. The interior of the cabinet contained three (3)raw wood shelves. The interior had grit, dust, and paper scraps.

c. There was dust, grit, and paper scraps beneath and behind the refrigerator.

d. In Room E-107, the Barber Shop:

(i) Five of five drawers had a heavy accumulation of hair.

(ii) There was dust on the window sills and screens.

(iii) There was hair on the floor.

e. In Room E-115, the Group Room:

(i) One recessed light bulb was out.

(ii) There were paper pictures glued to the exterior of a wooden cabinet. The interior and exterior of the cabinet were raw wood.

(iii) There were broken and missing floor tiles near the door to Room E-115-A.

f. In Room E-106, the Clean Linen Room:

(i) Three (3) large lights were leaning against the wall.

(ii) The cover for a recessed light was hanging by three corners from the ceiling.

(iii) A floor tile next to the heater was not glued to the floor.

g. In Room E-109-B, a Patient Bathroom, the paint on the electric hand dryer was peeling.

h. In Room E-102, the Activities Room:

(i) Boxes, bins of magazines, yarn, C-Fold towels, cloth towels, newspapers, paint supplies, and other supplies were stored under the sink.

(ii) There was dust, grit, beads, and paper scraps on the floor behind the stereo.

i. In Room E-130, the Laundry Room:

(i) The dryer filter contained heavy dust, hair, and lint.

(ii) There were towels and a thick pink fluid spilled on the floor.

j. In Room E-144-A, the Omni Cell Room:

(i) Floor tiles were out of place under the sink.

(ii) The floor had heavy black stains on it.

(iii) The paper towel dispenser was heavily rusted.

(iv) An old sharps container bracket on the wall was dusty with dried leaves on it.

k. The cover for a recessed light in Room E-148 was hanging by three corners from the ceiling and there were small holes in the wall.

10. A tour of Drake East One Unit on 7/14/16 revealed the following:

a. In the Greeting Area, the inside of a drawer had dust, an opened individual pack of triple antibiotic ointment, paper, grit, and other refuse.

b. A wall bracket with wooden bins on the floor was covered in dust.

c. There was delamination on the swing door.

11. A tour of Drake East Two Unit on 7/14/16 revealed the following:

a. In the Nurses Station, the sheetrock near the access panel was approximately 5 short at the top.

b. In Room E-248, a bathroom:

(i) There was a stained ceiling tile.

(ii) There was a sticky substance on a floor tile next to the sink.

(iii) There was cracked and missing caulking on the toilet and sink.

c. In the Nurses Station:

(i) There were two holes in the wall.

(ii) There was a stained ceiling tile.

(iii) Behind and beneath a metal cabinet was a heavy accumulation of dust, grit, paper scraps, dried rubber bands, staples, and food particles.

(iv) The desk had sections of delamination.

d. In the Sun Porch there was a raw wood shelf holding the DVR/DVD player.

e. In Room E-234, the Restraint Room:

(i) The room was very humid and the floor was wet.

(ii) The ceiling around the fire alarm had exposed wood and plaster.

f. In Room E-233, the Janitor's Closet, the back of a water fountain was protruding from the wall into the room. The wall around the protrusion was not finished, exposing wood and metal.

g. Room E-237, a Comfort Room was very humid.

11. A tour of Drake West Two Unit on 7/15/16 revealed the following:

a. In the Nurses Station:

(i) The floor under the counter had dust, grit, paper scraps, a needle cap, food particles, medication wrappers, crumpled carbon paper, and other refuse.

(ii) There was a missing section of wall covering to the left of the door as one enters the Nurses Station.

(iii) A section of floor molding was unattached to the wall.

(iv) The bottom drawer under the counter contained crumbled particle board pieces, paper scraps, dust, and grit.

(v) A black metal cabinet under the counter had a heavy accumulation of dust and tape residue atop it.

(vi)Two shoes on the floor had a heavy accumulation of dust on them.

(vii)A "Females" drawer had crushed particle board pieces, dust, grit, a used alcohol pad wrapper, and other refuse in it.

b. In Room W-247:

(i) In the Access Panel area there were broken ceiling tiles with wires protruding out of the opening.

(ii) The reverse side of a piece of sheetrock was leaned against the wall with exposed gypsum. The sheetrock was approximately 12 inches short at the top of the panel leaving a hole.

(iii) The floor in the alcove containing the Access Panel had a heavy accumulation of dust.

(iv) A hole in the floor of the Access Panel are had a walking cane sticking out of it.

(v)There were raw wood shelves in the Access Panel area.

(vi) Two badly degraded individual packs of sugar, dust, and tacky stains were atop a PNEUMODULAR CONTROL SYSTEM box.

(vii) A raw wood shelf was holding a DVD player.

(vii) The bottom of a black metal cabinet was stuck to the floor with rust.

c. In the Nurses Station, the desk had raw wood and delamination in areas.

d. In the Medication Room:

(i) There were penetrations in the wall next to the air conditioner and unpainted joint compound on the wall next to the air conditioner.

(ii) There was peeling paint under the soap dispenser.

e. In Room C-201, the Exam Room:

(i) There was no soap dispenser near the sink, only hand sanitizer in a dispenser.

(ii) The bottom of the door on the inside of the room was delaminated at the bottom.

(iii)A piece of cookie or chip, dust, and grit were on the top shelf and dust on the bottom shelf of the Code Cart.

(iv) A raw wood backboard was leaning against the wall.

(v)There were three (3) stained ceiling tiles.

f. In Room W-234, the Quiet Room:

(i) The floor beneath the restraint bed had fluid on it and the mattress was stuck to the floor. There were red stains, dust, grit, a ball point pen and raised stains under the bed.

(ii) There was a hole in the wall beneath the window.

g. In the Female Day Room there were seven (7) broken floor tiles and one recessed light bulb was out.

h. In the Male Day Room:

(i) There were seven (7) broken floor tiles.

(ii) Five (5) light covers had dead bugs atop them.

(iii) One (1) light cover had a yellow stain atop it.

i. In Room 209-B:

(i) The plastic wall covering was off exposing paper and glue.

(ii) The interior of the door was delaminated at the bottom.

j. In the Hallway, a mirror had sticker residue on the wooden frame. The bottom piece of the frame was separating from the sides.

k. In Room C-205, the Visitors Room:

(i) There were dead bugs atop and stains on two (2) recessed light covers.

(ii) There was paper dried to the floor, dust, grit, a salt packet, and paper scraps on the floor behind and beneath a metal cabinet. The cabinet was rusted to the floor.

(iii) A board behind the television was made of raw wood and there was heavy dust atop the television.

(iv) In Rooms C-205-B, C-205-C, and C-205-D there was a heavy accumulation of dust , grit, broken plastic pieces, and crud on the floor. There were missing ceiling tiles and storage bags of clothing on the floor.

B. Based on observation and review of documentation provided by administrative staff, it was determined that the facility failed to ensure that the physical plant was developed and maintained in such a manner to ensure the safety and well-being of patients by providing anti-ligature hardware.

Findings include:

Review of documentation provided by Administrative Staff #7 indicated:

1. Patient rooms, with the exception of two, in the Raycroft Unit lacked:

a. Anti-ligature door locksets and hinges.

b. Anti-ligature lights.

c. Anti-ligature lavatories and faucets.

d. Flush mount vent covers.

2. Patient rooms, with the exception of two, in the Drake Unit lacked:

a. Anti-ligature door locksets and hinges.

b. Anti-ligature lights.

c. Anti-ligature lavatories and faucets.

3. Patient rooms, with the exception of two, in the King Unit lacked:

a. Anti-ligature door locksets and hinges.

b. Anti-ligature air conditioner supply and return vents.

c. Anti-ligature radiator covers.

d. Anti-ligature shower fixtures.

4. Patient rooms, with the exception of two, in the Lazarus Unit lacked:

a. Anti-ligature door locksets and hinges.

b. Anti-ligature air conditioner supply and return vents.

c. Anti-ligature radiator covers.

d. Anti-ligature shower fixtures.

5. Patient rooms, with the exception of two, in the Kennedy Unit lacked:

a. Anti-ligature door locksets and hinges.

b. Anti-ligature air conditioner supply and return vents.

c. Anti-ligature radiator covers.

d. Anti-ligature shower fixtures.

6. 15 male rooms and 6 female rooms in the Lincoln Unit lacked anti-ligature door locks.



















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Based on observation and staff interview, it was determined that the facility failed to ensure adequate facilities for its services.

Findings include:

1. On 7/15/16 at 10:05 AM, in the presence of Staff #5, Staff #7, and Staff #35, no janitorial room was available in the Main Kitchen.

a. During interview, Staff #35 stated, "We dump the mop buckets in the floor drain in the middle of the kitchen."

2. On 7/15/16 at 10:45 AM, in the presence of Staff #5 and Staff #7, no janitorial room was available in the Raycroft Building. Cleaning supplies including clean mop heads were stored outside on the loading dock of the Raycroft Building.

Based on review of a nationally recognized standard, observation, and interview with administrative staff, it was determined that supplies and equipment are not maintained to ensure an acceptable level of safety and quality.

Findings include:

Reference: NFPA (National Fire Protection Association) 10 Portable Fire Extinguishers, 1998 edition 7.2.4.1.4 states: " Records for manual inspections shall be kept to demonstrate that at least the last 12 monthly inspections have been performed.

1. On 7/12/16, a fire extinguisher in the Medication Room of King Unit was observed on the floor in the corner of the room. The inspection tag indicated it to have last been inspected in September 2015.

2. On 7/12/16, a cabinet above the refrigerator in the Pantry of Kennedy Unit was found to have five (5) individual coffee creamers. The containers included the directions "Keep Refrigerated."

3. On 7/12/16, a cabinet in the Medication Room of Lazarus Unit was found to contain a Universal Viral Transport for Viruses, Chlamydiae, Mycoplasmas, and Ureaplasmas kit with an expiration date of 2016-03 (3/31/16).

4. A tour of Raycroft East One Unit on 7/13/16 revealed:

a. A cabinet above the sink in the Medication Room was found to contain an unopened container of yogurt. The container included the instructions "Keep refrigerated." The Nurse Manager of the Unit, Administrator #39, stated that the yogurt was for patient use.

b. A freestanding cabinet in the Medication Room contained three (3) BBL (Becton, Dickinson and Company) CultureSwab Plus Collection and Transport System packages with an expiration date of 2016-05 (May 31, 2016).

5. A tour of Raycroft West One Unit on 7/13/16 revealed:

a. A drawer under the countertop in the Nurses Station contained new hair brushes, one hair brush with a small amount of hair in it, and three hair brushes with large amounts of hair in them.

b. A freestanding cabinet in the Medication Room contained two (2) boxes of Retractable Technologies 5 cc (cubic centimeter) syringes with needles with an expiration date of 2013-10 (10/31/13) and multiple outdated 5 cc and tuberculin syringes with needles.

6. On 7/13/16, a freestanding cabinet in the Medication Room of Raycroft East Two Unit was found to contain a 3 cc syringe with an expiration date of 2-2016 (2/29/16).

7. On 7/14/16, a heavily frosted freezer in the refrigerator of the Drake Admissions Unit was observed. The top gasket of the refrigerator was heavily encrusted with food and coffee particles.

8. A tour of Drake West Two Unit on 7/15/16 revealed:

a. The examination table drawer in Exam Room C-201 contained:
(i) Four (4) Para-Pak C&S (Culture & Sensitivity) Stool transport vials containing C&S medium for the transport of enteric pathogens. Two (2) of the vials had an expiration date of 2015-09 (9/30/15), one (1) vial had an expiration date of 2015-01 (1/31/15), and one (1) vial had an expiration date of 2016-04 (4/30/16).
(ii) Two Para-Pak PVA (Polyvinyl Alcohol) Fixative specimen containers with an expiration date of 205-04 (4/30/15).
(iii) A Para-Pak 10% Formalin Stool Transport vial with an expiration date of 2015-04 (4/30/15).
(iv)Three (3) Urine Specimen Collection Kits . Two of the kits had an expiration date of 2015-07-31 (7/31/15) and two kits had an expiration date of 2015-06-30 (6/30/15).
(v)One (1) sterile Suture Removal Kit was opened and resealed with surgical tape.
b. A cabinet above the sink contained one (1) 18 Ch/Fr (French/Charriere) catheter with an expiration date of 2016-06 (6/30/16).

9. On 7/15/16 at 9:50 AM, in the presence of Staff #5, Staff #7, and Staff #35, the thermometer in refrigerator #2, in the Main Kitchen was reading 44 degrees Fahrenheit.

a A review of the facility Monthly Log for July 2016 confirmed Refrigerator #2's temperature was as recorded above the 41 degree Fahrenheit every day between July 2, 2016 and July 15, 2016.

b. During interview, Staff #35 confirmed notification as made to Maintenance but no action has been taken to correct the problem.

(i) Staff #35 confirmed refrigerator #2 is still being utilized.

10. On 7/15/16 at 9:55 AM, in the presence of Staff #5, Staff #7, and Staff #35, the ice machine identified with property tag 039 located in the Main Kitchen had a black substance which was visible on the inside where the ice was stored.




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