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Based on observation and staff interview, it was determined the facility failed to maintain the hospital environment so the safety well-being of patients was assured. This resulted in writing on the walls in the adolescent unit that could be potentially mentally harmful to young psychiatric patients and broken fixtures in use in patient rooms. Findings include:

Observations of the facility were conducted on 12/16/25 beginning at 10:00 AM with the DCS and EVS Manager.

1. While touring the adolescent unit, the following potentially triggering messages and expletives were observed written on the walls and surfaces in rooms that were ready for patient use, including but not limited to:

- "Trust no one unless you want your heart ripped out of your chest"
- "This staff makes everything worse"
- "Suck my balls"

The walls also contained numerous pencil drawings and numerous other expletives.

The DCS and EVS Manager were interviewed at the time of the observations and acknowledged the drawings and messages written on the walls. The EVS Manager stated they needed to be painted over.

2. In the adult unit, the area around the sink was observed to be chipped, exposing the raw wood underneath.

The DCS and EVS Manager were shown the sink at the time of observation and acknowledged it was chipped.

The facility failed to maintain the hospital environment so the safety and well-being of patients was assured.

Based on observation and staff interview, it was determined the facility failed to maintain a clean and sanitary environment to avoid sources and transmission oof infection. This had the potential for cross contamination between patients. Findings include:

Observations in patient care areas were conducted on 12/16/25 beginning at 10:00 AM with the Director of Clinical Services (DCS) and the EVS manager. The following infection control concerns were identified in rooms which were unoccupied and ready for patient use:

- Food crumbs on the floor
- Hair on the shelves
- Thick dust on shelves
- Patient belongings on shelves
- Used bath products in the shower
- Pink stain in the shower floor
- Large dark stain, appeared to be mildew, on the shower curtain
- Trash remaining in the trash can
- Paper trash bags contained brown residue and caused the bag to be stuck to the floor
- Hair in the trash can
- Floors and walls in the bathrooms were visibly dirty, including grime and hard water stains
- Dried dark brown stain along where the bed was connected to the floor

The DCS and EVS Manager were shown the observations at the time they were seen. The EVS manager stated rooms were cleaned daily and between admit. She stated floors were mopped regularly but did not get scrubbed. She stated showers were cleaned every other day and shower curtains were laundered every other week. The EVS Manager acknowledged the areas of concern and stated the building was old and cleaning was a challenge.

The facility failed to maintain a clean and sanitary environment