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250 COLLEGE AVENUE

LANCASTER, PA null

MAINTENANCE OF PHYSICAL PLANT

Tag No.: A0701

Based on a observation, and interview with staff (EMP), it was determined the facility failed to maintain an environment that assured well being of patients.

Findings include:

A tour of the facility on September 3, 2015, revealed room 363 had a stained off white cloth shower curtain with three yellow stains on the shower curtain. There were also two specks of brown on the shower curtain. Room 363 had paint that bubbled on an outside wall. The baseboard was damaged. The walls were marred.

A tour of room 362 revealed the off white cloth shower curtain had yellow stains. The walls were marred.

A tour of room 534 revealed the wall paper coming off in the bathroom and the wall grout needed repaired.

A tour of ICU 8 revealed a hole in the wall.

An interview conducted on September 9, 2015, at 2:00PM with EMP1 confirmed the above findings.

An interview conducted on September 9, 2015, with EMP3 revealed that twice a year EMP3 goes to each floor and completes environmental rounds EMP3 stated that if a patient is in the room they do not go into the room.