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Based on observation and interview, it was determined the facility failed to assure the environment on the Children's Unit was clean, maintained and free of damaged furnishings. The facility could not assure the patient would be protected from injury if exposed to the affected areas. The failed practice affected the 11 patients on the Children's Unit (one acute and ten sub-acute patients) and had the potential to affect all admissions to the Unit. The findings were:

A. The Children's Unit was observed on 05/16/12 from 0811 through 0900. Twelve patient rooms (#233-244) were observed at that time. One (#341) of 12 rooms observed had accumulations of dirt along the floor baseboards and on the bathroom floor and shelves. The hallways of the Unit were also observed to have accumulations of dirt in the corners and along baseboards. One of four chairs beside a table in the Day Area was observed with stains. The findings were confirmed by Environmental Services employee #1 at 0850 and by the Housekeeping Supervisor at 0900 on 05/16/12.

B. Patient room #314 was observed on 05/16/12 while on tour from 0811 through 0900. The left side of the door facing inside room #314 was observed to have an area of peeled and chipped paint with the surface beneath the paint exposed. The room baseboards were damaged in seven places with the surface beneath the paint exposed.

The Day Area of the Children's Unit was observed at 0845 and included three of four desk chairs in use, with one or more areas in which the laminate had been removed in an irregular fashion. The wood beneath the laminate surface was exposed and sharp areas were observed. A round table in the day area had an area on the side of the top surface in which the laminate had been removed with the wood beneath exposed. The findings were confirmed by the Children's Unit Nurse Manager at 0848. The Maintenance Director for the facility also confirmed the findings at 0958 on 05/16/12.

C. The Facility Policy #1240 titled "Therapeutic Environment" was reviewed on 05/16/12. Item A.5. stated "Housekeeping service is provided daily to keep all areas clean and free from undesirable odors." Item C.5. stated "Day rooms are available on each Unit. These rooms are furnished with comfortable, age appropriated furniture..." Item C.7. "There is a written work order system that facilitates prompt repair of broken furnishings and equipment."