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Based on observations and interviews, the hospital failed to meet the Condition of Participation relative to the Governing Body as evidenced by failing to ensure the overall hospital environment was maintained in a manner to ensure the safety and well-being of patients. This deficient practice was evidenced by failure to maintain a clean and safe environment as evidenced by multiple breaches in the quality, safety and infection control in the environment of care. (See findings in tags A0115, A 0700, A747).

Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights.

1. The hospital failed to ensure patients received care in a safe setting as evidenced by failure to mitigate known ligature risk for 7 (#7-13) of 7 (#7-13) patients reviewed who were on suicide precautions and their accessible toilets had the seats removed leaving a hole through the porcelain which could be utilized as a ligature point.
2) failing to ensure 32 (S10RN, S11RN, S12RN, S13RN, S14RN, S15LPN, S16LPN, S18LPN, S19LPN, S8MHT, S20MHT, S21MHT, S22MHT, S4MHT, S23MHT, S24MHT, S25MHT, S26MHT, S27MHT, S28MHT, S29MHT, S30MHT, S31MHT, S32MHT, S33MHT, S34MHT, S7MHT, S35MHT, S36MHT, S37MHT, S38MHT, S39MHT) of 59 direct care staff maintained certification in CPR/AED; and failing to ensure 20 (S10RN, S11RN, S14RN, S40RN, S41RN, S15LPN, S16LPN, S17LPN, S18LPN, S19LPN, S8MHT, S21MHT, S26MHT, S27MHT, S28MHT, S34MHT, S36MHT, S37MHT, S38MHT, S39MHT) of 59 direct care staff were competent with current certification in Crisis Intervention Training;
3) Air-conditioner missing vent cover exposing the rotation fan;
4) Plastic bags throughout the facility;
5) Failed to document 15 minute observation on Patients #14-20.
(See findings under tag A-0144).

An Immediate Jeopardy situation was identified on 06/15/2023 at 5:05 p.m. and reported to S1Adm and S2DON via telephone. The Immediate Jeopardy was a result of the hospital failing to mitigate ligature risk for patients admitted for being suicidal.

On 06/19/2023 at 3:30 p.m. S1Adm presented the plan for lifting the immediacy of the IJ situation and the plan included the following.
1. Admissions are stopped. In response to this potential threat for patient safety, the facility stopped admitting patients until the identified patient room issues are resolved.
The hospital's medical director and clinical staff was informed of the decision to cease admissions until the issues on the nursing units were effectively addressed and to immediately correct the findings.

2. On June 16, 2023, the Administrator immediately contacted and met with the hospital's Director of Nursing and all of the maintenance staff to be available for work at 7:00 am Friday, June 16, 2023 to initiate the following environmental improvements to decrease the risk of patient harm.

3. On June 16, 2023, the Director of Plant Operations purchased nylon threaded bolts that would mount flush into the holes. The bolts were installed in all patient and seclusion rooms. The bolts were further secured with contractor grade liquid nails to permanently affix and seal the bolts.

4. The level of continued patient observation is every 15 minutes. The Director of Nursing will be adding 3 additional Mental Health Technicians (MHTs) for each unit for patient safety, observation and monitoring of patients while the installation occurred.

Immediate Notification and Action Items Summary:
- Notified and communicated with Corporate Compliance team about IJ and recommended POC 6/15/2023.
- Notified BRBH leadership team 6/15/2023.
- Debriefed as a team at BRBH 6/16/2023 on plan of action.
- Purchased nylon, flush fit bolts from Lowes 6/15/2023.
- Locked and closed all non-assigned rooms and spaces 6/16/2023.
- Assigned additional MHTs to patients for Q-15 Observation 6/16/2023.

Compliance Actions
To guarantee compliance moving forward, BRBH staff will include the installed bolts in the daily EOC rounds. This will be reviewed by the Director of Nursing during daily morning unit rounding. The Administrator will check at weekly increments to ensure compliance and the units are being correctly monitored. The Director of Plant Operations will add this additional rounding to the daily EOC rounds. If any tampering or changes occur, the Director of Plant Operations is instructed to communicate with the Nursing Director to move the patient and close the room until the room toilet is evaluated and/or repaired. These new processes will monitor compliance and include data daily and weekly for leadership review.

The Director of Plant Operations/Designee is responsible for Weekly Environment of Care Safety Inspections and the completion of the Environment of Care Safety Inspection Checklist to ensure logs are completed. Following the inspections, the Director of Plant Operation will report any identified areas of concern to the Administrator for the implementation a corrective action plan.

The results of the Weekly Environment of Care Safety Inspections will be aggregated into usable data and analyzed to determine a monthly compliance percentage. Monthly reports of the Environment of Care Safety Inspections will be tracked, trended and reported by the Director of Plant Operation monthly to the Safety and Performance Improvement Committees for review, discuss and implementation of corrective action, if warranted.

Leadership Involvement
The Administrator and the Leadership Team will provide appropriate oversight of the ongoing corrective action plan to ensure that the hospital establishes and maintains a safe and functional environment for the safety, well-being and needs of the patient population by providing an environment with ligature free points. The Administrator and Leadership Team are responsible for monitoring compliance of corrective action plans and for reporting the facility's progress to the Corporate Quality Compliance Team and working with the Board of Directors to improve facility processes that need improvement.
The Corporate Quality Compliance Team, the Chief Medical Officer and the Chief Nursing/Quality Compliance Officer, who are members of the Board of Directors, provide oversight of the corrective action plan for the facility, which includes the development of appropriate action plans for identified deficiencies, implementation of action plans and ongoing monitoring of compliance. The Corporate Quality Compliance Team will confer weekly with Hospital Leadership, whether individually to focus on specific departmental corrections, or as a Leadership group, to support the ongoing corrective action and monitoring process.

The Corporate Quality Compliance Team will share the facility's ongoing Hospital systems process improvement with the Board of Directors through weekly conference calls/updates and/or attending the Board of Directors meetings as required.

Preventive Analysis
In order to prevent future occurrences of this issue from occurring again, it is necessary for the Administrator to provide constant monitoring and oversight of the action plans implemented to ensure that the hospital establishes and maintains a safe and functional environment for the safety, well-being and needs of the patient population by providing an environment free of patient harm concerns. The Administrator is responsible for reporting the facility's progress to the Corporate Quality Compliance Team and working with the Board of Directors to improve facility processes that need improvement to ensure the Governing Body oversees the safety and quality of care, treatment, and services provided at the hospital.

On 06/19/2023 at 3:30 p.m.the IJ was lifted.

Based on observation and interview, the facility failed to ensure care in a safe setting. The deficient practice is evidenced by:
1) Multiple ligature risks;
2) failing to ensure 32 (S10RN, S11RN, S12RN, S13RN, S14RN, S15LPN, S16LPN, S18LPN, S19LPN, S8MHT, S20MHT, S21MHT, S22MHT, S4MHT, S23MHT, S24MHT, S25MHT, S26MHT, S27MHT, S28MHT, S29MHT, S30MHT, S31MHT, S32MHT, S33MHT, S34MHT, S7MHT, S35MHT, S36MHT, S37MHT, S38MHT, S39MHT) of 59 direct care staff maintained certification in CPR/AED; and failing to ensure 20 (S10RN, S11RN, S14RN, S40RN, S41RN, S15LPN, S16LPN, S17LPN, S18LPN, S19LPN, S8MHT, S21MHT, S26MHT, S27MHT, S28MHT, S34MHT, S36MHT, S37MHT, S38MHT, S39MHT) of 59 direct care staff were competent with current certification in Crisis Intervention Training;
3) Air-conditioner missing vent cover exposing the rotation fan;
4) Plastic bags throughout the facility;
5) Failed to document 15 minute observation on Patients #14-20;
6) Presence of shorts with a drawstring;
7) Direct observation of Unit 1 seclusion room revealed the light fixture above the restraint bed with the light cover open and hanging exposing the lights and wires;
8) Showers and sinks that overflow onto the floor and
9) Toiletry items not secured throughout the facility
Findings:

Review of the facility booklet titled, "Baton Rouge Behavioral Hospital New Hire Orientation and Annual Mandatory Employee Orientation Education Self- Study Packet and Exam 2023, "revealed in part, "National Patient Safety Goals . . . 8. Identify Safety Risks inherent to the patient population. a. The hospital conducts an environmental risk assessment that identifies features in the physical environment that could be used to attempt suicide; the hospital takes necessary action to minimize the risk. . . Identification of Hazards- Our first goal should always be to identify hazards before they lead to an adverse event."
Tour of the facility revealed the following:

1) Multiple ligature risk.

Direct observation during tour of the facility revealed toilets in several patient rooms with the seats removed and open holes where the seat was previously attached.

Direct observation during tour of the facility revealed several patient rooms with toilets and sinks with aprons that did not fit appropriately. The poorly fitting aprons were ineffective in eliminating the ligature risk and provided a place for hiding contraband.

Direct observation of Unit 1 Seclusion room revealed a wooden chair with open arm rails which could be utilized as a ligature point.

Direct observation of Unit 2 seclusion room door revealed 3 individual hinges which could be utilized as a ligature point.

At the time of discovery during the tour between 9:15 a.m. and 11:30 a.m., S2DON verified the above ligature risk and the lose aprons provided a place for contraband to be hidden.

A tour of the hospital on 06/15/2023 at 3:25 p.m. the following patient rooms were identified has having toilets missing toilet seats and holes through the porcelain that could be used as ligature points; "F", "J", "K", "L", "M", "Q", "R".

In an interview on 06/15/2023 at 3:55 p.m. S5RN verified the above patient rooms has having ligature risk with the holes in the toilets and stated the following patients were on suicide precautions and occupied the above rooms: "F", "J", "K", "L", "M", "Q", "R".

A tour of the seclusion Room on Unit 1 revealed a toilet seat with hinges which could be used as a ligature point.

In an interview on 06/15/2023 at 3:27 p.m. S6AdmAst verified the ligature findings.

In an observation on 06/15/2023 at 3:50 p.m. on unit #2, the door to Patient Room "W" was open and accessible to patients. The toilet had holes which could potentially be used as a ligature point.

In an interview on 06/15/2023 at 3:51 p.m. with S6AdmAst, she verified the above mentioned findings.

In an observation on 06/15/2023 at 3:50 p.m. on unit #2, the door to patient room "W" was open and accessible to patients. The toilet had holes which could potentially be used as a ligature point.

In an interview on 06/15/2023 at 3:51 p.m. with S6AdmAst, she verified the above mentioned findings.

2) Failing to ensure 32 (S10RN, S11RN, S12RN, S13RN, S14RN, S15LPN, S16LPN, S18LPN, S19LPN, S8MHT, S20MHT, S21MHT, S22MHT, S4MHT, S23MHT, S24MHT, S25MHT, S26MHT, S27MHT, S28MHT, S29MHT, S30MHT, S31MHT, S32MHT, S33MHT, S34MHT, S7MHT, S35MHT, S36MHT, S37MHT, S38MHT, S39MHT) of 59 direct care staff maintained certification in CPR/AED; and failing to ensure 20 (S10RN, S11RN, S14RN, S40RN, S41RN, S15LPN, S16LPN, S17LPN, S18LPN, S19LPN, S8MHT, S21MHT, S26MHT, S27MHT, S28MHT, S34MHT, S36MHT, S37MHT, S38MHT, S39MHT) of 59 direct care staff were competent with current certification in Crisis Intervention Training.

Policy/Procedure HR 2:038 titled, CPR/AED Certification Requirements revealed in part: No direct care staff may begin work on a unit until they have submitted a copy of their CPR/AED to Human Resources Director. The Human Resources Director shall maintain a list of current CPR/AED status of clinical staff with expiration dates.

Review of the HR Directors list revealed expired or missing CPR/AED certification for 32 (S10RN, S11RN, S12RN, S13RN, S14RN, S15LPN, S16LPN, S18LPN, S19LPN, S8MHT, S20MHT, S21MHT, S22MHT, S4MHT, S23MHT, S24MHT, S25MHT, S26MHT, S27MHT, S28MHT, S29MHT, S30MHT, S31MHT, S32MHT, S33MHT, S34MHT, S7MHT, S35MHT, S36MHT, S37MHT, S38MHT, S39MHT) of 59 current direct care employees.

Review of the HR Directors list revealed expired or missing CPI certification for 20 (S10RN, S11RN, S14RN, S40RN, S41RN, S15LPN, S16LPN, S17LPN, S18LPN, S19LPN, S8MHT, S21MHT, S26MHT, S27MHT, S28MHT, S34MHT, S36MHT, S37MHT, S38MHT, S39MHT) of 59 current direct care employees.

In an interview on 06/21/2023 at 10:40 a.m., S3HR Director acknowledged that all direct care staff are to have current CPR and Crisis Intervention Training.

3) Air-conditioner missing vent cover exposing the rotating fan which could cause serious injury if a patient were to place their hand in the opening.

Direct observation of Unit 1 TV room reveled the air-conditioner window unit was noted to have a missing vent cover exposing the turning fan, which could cause serious injury if a patient were place a body part in the opening.

In an interview on 05/30/2023 at 12:09 p.m. S2DON verified the missing vent cover and potential danger.

A tour of Unit 1 TV room on 06/15/2023 at 3:33 p.m. revealed Patient #15 and #16 watching TV. Further observation revealed the air-conditioner window unit was in use again with the vent cover missing and the turning fan was exposed, which could have resulted in patient injury.

In an interview on 06/15/2023 at 3:33 p.m. S6AdmAst verified the above findings.

4) Plastic bags in patient care areas.

Direct observation during the tour revealed small sandwich size plastic bags in multiple rooms on both units in the facility. The plastic bags were used for bread at meals and also for sandwiches given to the patients. The plastic bags were also used as wrappers for the toothbrushes and feminine hygiene products given to the patients. Plastic bags were used on the refreshment table to cover the cups.

An observation of Unit 1 dining room revealed a large trash can with a plastic trash bag.

At the time of discovery, S2DON verified the food, toothbrushes, cups and feminine products came in plastic bags and were not removed before giving them to patients.

Tour of common room a revealed rolls of white and blue plastic bags and open boxes of nitrile gloves on the countertop.

In interview on 05/31/2023 at 10:41 a.m. S4MHT verified the presence of the plastic items on the countertop. S4MHT verified the patients pass though the room several times a day to exit the building to the smoking area and could easily grab them.

During a tour of the hospital on 06/15/2023 at 3:25 p.m. a linen hamper was observed outside the soiled linen room. The hamper had a large plastic bag liner that was accessible to patients.

In an interview on 06/15/2023 at 3:27 p.m. with S6AdmAst, she verified the above mentioned findings.

5) Failed to document 15 minute observation on Patients #14-20

A review of S9MHT's observation sheets for 06/15/2023 at 3:00 p.m. revealed she had not documented her 15 minute observations on her patients, Patient #14- #20, since 2:00 p.m. None of the patients were on suicide precautions.

In an interview on 06/15/2023 at 3:01 p.m. with S9MHT, she was asked why she had not documented in an hour. She said she was a little behind. When asked how she could remember where each patient was in 15 minute increments to accurately document, she said she jotted it down on a scratch piece of paper. A copy of the scratch piece of paper was requested but was never provided.


6) Presence of shorts with a drawstring in a patient's possessions.

Direct observation during tour of the facility revealed a pair of shorts with a drawstring in a patient room.

At the time of discovery on 05/30/2023 at 11:04 a.m., S2DON verified the clothing should have been inspected and the drawstring should have been removed when the patient was admitted.

7) Direct observation of Unit 1 seclusion room revealed the light fixture above the restraint bed with the light cover open and hanging exposing the lights and wires.

On 05/30/2023 at 12:00p.m. a direct observation of Unit 1 seclusion room revealed the light fixture above the restraint bed with the light cover open and hanging exposing the lights and wires.

In an interview on 05/30/2023 at 12:00 p.m. S1Adm and S2DON verified the above findings and verified the potential danger of any patient placed in the rooms.

8) Showers and sinks that overflowed onto the floor.

Tour of Unit 1 revealed and there was no shower curtain in Patient Room "B" with significant water on the floor.

Tour of Unit 2 revealed faucets that sprayed water onto the floor in the hall and in Patient Room "A".

At the time of discovery during the tour between 9:15 a.m. and 11:30 a.m., S2DON verified the water on the floor and the potential for falls.

9) Toiletry items not secured.

Direct observation during tour of the facility revealed all patient rooms and or bathrooms contained toiletry items including bottles of soap, mouthwash, toothpaste, deodorant, toothbrushes and plastic combs throughout the facility.

In interview on 05/31/2023 at 9:20 a.m., S2DON verified they did not restrict the use of the toiletry items and patients were allowed to keep toiletries in their rooms on both units. S2DON verified they were a safety issue.






44495

Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Physical Environment. This was evidence by:
1) The hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients, staff, and visitors. This deficient practice was evidenced by failure to maintain the physical plant in good repair and failure to maintain a safe patient care environment. (See findings in Tag A0701)
2) The hospital failed to maintain adequate temperature controls in patient rooms. (See findings in tag A0726)

An Immediate Jeopardy situation was identified on 06/15/2023 at 5:05 p.m. and reported to S1Adm and S2DON via telephone. The Immediate Jeopardy was a result of the hospital failing to mitigate elevated temperatures in patient rooms with windows that are secured and unable to be opened for ventilation.

On 06/19/2023 at 3:30 p.m. S1Adm presented the plan for lifting the immediacy of the IJ situation and the plan included the following.

On June 1, 2023, the Administrator contacted the hospital's corporate compliance team to brief them on the Complaint Survey Findings from the LDH's verbal summation.
On June 1 - 4, 2023, the Administrator and leadership team began developing a multi-point corrective action plan with required resources.
On June 5, 2023, a meeting was held with the Administrator, Nursing Director, and Plant Operations Director met to review the corrective action plans to ensure that the hospital establishes and maintains a safe and functional environment to meet the needs of the patient population. The hospital's patient care environment is required to be safe, clean and suitable for the care, treatment, and services by providing a safe environment without ligature points that has the potential to cause self-harm by the patient. The Administrator directed the Director of Plant Operations and Leadership Team to immediately begin the process for the resolution of the identified risks as identified by the LDH Surveyors.

Priority list and checklist of repairs and cleaning was developed by leadership, communicated with affected staff and implemented.

On June 6, 2023, the Administrator Team held a conference call with corporate senior leadership to review the findings from the survey and initiate a plan of correction on outstanding items. The focus was on the immediate resolution of all findings and specifically those involving safety and environmental deficiencies for potential of harm.

Immediate Focus: To correct the areas of non-compliance, BRBH began implementing the following actions on June 7, 2023. The corrective action plan is broken into 9 areas to encompass all areas discussed during debriefing with the State of Louisiana officials. The focus is on general cleanliness, repairs in halls and corridors, individual patient rooms, day rooms, seclusion rooms, storage spaces, lobby, parking lot, nursing station, and outside patient spaces.

Immediate Corrective Action Items Completed:
- Notified and communicated with Corporate Compliance team about Louisiana Department of Health's visit and recommended plan of corrections of 5/25/23 and 6/1/23.
- Notified BRBH leadership team 5/25/2023 with continuous communication.
- Debriefed as a team at BRBH 5/25/2023 & 5/31/23 on the plan of action.
- Developed high priority action work list - 5/29/2023
- Contacted and contracted Company A services to repair main HVAC 5/29/2023.
- Contacted Company B on 6/5/203, 6/15/2023, and 6/16/2023 regarding the PTAC covers and air flow issues.
- Contracted Company C for janitorial services. effective 6/2/2023
- Deep cleaned the facility with a team by Company C 6/2/2023 through 6/4/2023.
- Hired new maintenance team that started on 6/5/2023.
- Met with new maintenance team on 6/5/2023 to review plan and prioritize efforts.
- Secured additional funds from corporate for repairs on 6/5/2023.
- Repaired and/or replaced all fixtures identified by the LDH Surveyors per the hospital's work plan.
- Removed the PTAC covers in patient rooms, cleaned filters to allow the free flow of conditioned air (Permanent solution to the PTAC covers will be provided with vender).

Patient Room temperatures are returning to a normal range of between 68 and 76 degrees Fahrenheit as a result of this initial intervention of 6/16/23.

Compliance Actions
To insure compliance moving forward, administration has created a work order request process for maintenance services within the building. These request are reviewed daily as a team in the morning Flash meeting before the day starts. Daily environment of care rounds has been reinforced and logs developed for MHTs daily during firs and second shifts; and daily rounding and weekly logs for Plant Operations Director and staff, maintenance logs, system drills, including vehicle maintenance logs. The daily rounds by nursing MHT staff and maintenance staff provides additional "eyes on" the environment with the identification of areas requiring improvement and attention and prompt corrective actions.

The MHT and plant operations rounds logs are reviewed daily by leadership (Administrator, Director of Nursing) at the morning FLASH meetings to insure that the rounding is being completed twice a day, and that corrective actions are being identified and the work is being completed.

Environment of Care / EOC Management Expectations:
- Daily Log Rounds- First and 2nd Shift MHT temperature & maintenance inspection logs double checked by Director of Plant Operations & Director of Nursing (maintenance, temperature control & housekeeping needs).
- Daily/Weekly Logs & EOC Rounds - Director of Plant Operations/Administrator /DON
- Cleanliness of the environment of care: Plant Operations Director & DON
- Generator Management (Hurricane Readiness) - Director of Plant Operations
- Functional Work Order Process - Administrator & Plant Operations Director
- Responsive to patient complaints and concerns promptly: Clinical & Nursing Directors
- Safe & Ligature Resistant patient care environment - Administrator, Nursing Director and Plant Operations Director with the use of the Environmental Risk Assessment process.
- Fire Detection & Suppression System - Director of Plant Operations
- Emergency Preparedness & Readiness for the Hurricane Season - Director of Plant Operations & Senior Staff, as it affects utility management & temperature control.
Leadership Involvement;
The Administrator and the Leadership Team will provide appropriate oversight of the ongoing corrective action plan to ensure that the hospital establishes and maintains a safe and functional environment for the safety, well-being and needs of the patient population by providing an environment that is clean and without ligature points that have the potential to cause self-harm by the patient. The Administrator and Leadership Team are responsible for monitoring compliance of corrective action plans and for reporting the facility's progress to the Corporate Quality Compliance Team and working with the Board of Directors to improve facility processes that need improvement.
The Corporate Quality Compliance Team, provide oversight of the corrective action plan for the facility, which includes the development of appropriate action plans for identified deficiencies, implementation of action plans and ongoing monitoring of compliance. The Corporate Quality Compliance Team will confer weekly with Hospital Leadership, whether individually to focus on specific departmental corrections, or as a Leadership group, to support the ongoing corrective action and monitoring process.
The Corporate Quality Compliance Team will share the facility's ongoing Hospital systems process improvement with the Board of Directors through weekly conference calls/updates and/or attending the Board of Directors meetings as required.
Preventive Analysis:
In order to prevent future occurrences of issues from occurring again, it is necessary for the Administrator and hospital leaders to provide constant monitoring and oversight of the action plans implemented to ensure that the hospital establishes and maintains a safe and functional environment for the safety, well-being and needs of the patient population. The system of checks and balances that are put in place, such as the environment of care monitoring logs, daily and weekly EOC rounds, daily Flash meeting reviews of actions steps, and etc., are utilized to sustain the environmental improvements over time in providing for a well-cared for facility to conduct patient care.
The Administrator is responsible for reporting the facility's progress to the Corporate Quality Compliance Team and working with the Board of Directors to improve facility processes that need improvement to ensure the Governing Body oversees the safety and quality of care, treatment, and services provided at the hospital.


On 06/19/2023 at 3:30 p.m. the IJ was lifted.

Based on observations and interviews, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients, staff, and visitors. This deficient practice was evidenced by failure to maintain the physical plant in good repair and failure to maintain a safe patient care environment.

Findings:

During a tour of the hospital on 05/25/2023 at 3:30 p.m. with S2DON the following was observed:

Exterior:
Overhang noted to be missing paint, cob webs and rust.
Fascia board with hole and appears rotten.
Gutter hanging, Gutter section missing, gutter down spout broken, missing light fixture on exterior wall.
Patient Room "O"- 2 windows with cracked glass, cob webs around windows. Missing glass covered with plastic sheeting.
Admission office windows covered with dust, cobwebs and peeling paint.
Covered walkway concrete covered with spots of dark stick substance appearing to be gum, cobwebs noted throughout the ceiling.

Interior:
Reception desk/ counter was noted to be sticky, peeling paint, bare wood, floor area under receptionist chair was noted worn through to the concrete.

In an interview on 05/30/2023 at 11:23 a.m. S5Rec, stated the reception area has been in the above condition for 2 years.

Unit 1:
Medication room counter was noted to have bare wood, peeling paint and floors were gray in color.
The patient vital sign room was noted to have a desk with peeling paint\, stick substance, floors were covered with gray substance and the wall had peeling paint.
Nurse's station was noted to have broken and missing Formica with bare wood, peeling paint, tape stuck to the counters, floors covered with gray substance, the air-conditioner duct was covered with a gray fuzzy substance.
Patient Laundry room door hinge was broken, floor dirty with brown substance, opening in the ceiling and paint peeling.
Dining room: walls with bare sheet rock, walls with brown substance dripping near the trash can, floor with gray sticky substance, .
Dining area bathroom closest to the nurse's station was noted to have peeling paint, no paper towels or soap.
Dining area second bathroom was noted to have wet musty blankets on the floor, air vent pulled from the ceiling, sheetrock broken, metal vent cover was on the floor, paint peeling from the ceiling, black substance on the door frame.

Soiled linen closet was noted to have missing floor molding, floor was stained and sticky to the touch.

Seclusion room was noted to have cob webs with spiders noted in the corners. There was broken floor tile, hole in the wall and the floor was dirty with a gray substance. The door was noted to have a white substance and bare wood was noted on the bathroom door.
The bathroom was noted to have a dead roach on the floor, floor was dirty with a white and brown substance, door frame peeling paint, shower wall off, shower curtain covered with black substance, toilet seat noted as ligature risk.

Unit 2 TV room baseboards were peeling off the walls.

Housekeeping closet floor was noted to be covered with gray sticky substance and a hole in the wall.

Patient Room "H" bathroom sheetrock was peeling, shower curtain covered with black substance, back of toilet missing caulk, vent covered with gray fuzzy substance, doorframe peeling and rusty, floor was noted to have black- gray and white substance on it and the bath room door had bare wood.

Patient Room "I" had bare wood on the bathroom door and was closed for patient use.

Patient Room "C" air-conditioner vent covered with gray fuzzy substance, toilet was cracked and leaking. Shower wall was broken with a hole, shower curtain was noted with brown substance, mirror hanging off the wall, wall was peeling.

Unit 2:
Seclusion room dead roach, gray stains on the floor, and camera with exposed wires. The bathroom door had bare wood, floor missing several 1 foot square tiles, shower wall peeling off, pink substance on shower walls and the ceiling contained a black substance.

Patient Room "E" bathroom door had bare wood, shower curtain with brown substance, rust around the toilet, back of the toilet coming off the wall with lose screws, air-conditioner vent covered with gray fuzzy substance. The shower had a black substance on the floor and walls.

Patient Room "J" bathroom door had bare wood, bathroom ceiling had black substance, sheet rock peeling, floor covered with black and white substance, no soap or paper towels.

Patient Room "F" bathroom door with bare wood, no shower curtain, peeling paint, ceiling cracked and peeling, missing caulk around the toilet, sink coming off the wall, shower stall with holes and black substance on the walls.

Ceiling near the nurse's station noted to have a hole, ceiling cracked and peeling in the hallway and the air-condition vents covered with gray fuzzy substance.

Patient Room "A" window was noted to be shattered and intact, door frame peeling paint, bathroom door had bare wood, paper towel dispenser was broken, and the air-conditioner vent was covered with gray fuzzy substance.

Outside smoking area was noted to have rotten fascia boards and missing light bulbs.

Patient Room "K" was missing floor tile in the bathroom, bare wood in the bathroom, wall peeling and sink coming off the wall.

Patient Room "L" had a hole a little smaller than a basketball in the wall at the head of the bed and peeling baseboards.

Patient Room "G" toilet apron had exposed screws, no toilet seat, and paper towel holder coming off the wall with holes in the wall.

Patient Room "N" was noted to have bare sheetrock, peeling paint, floor tiles, missing baseboards and the mattress was torn.

A review of the onsite EOC & Life Safety Review dated March 06/10/2022 completed by the corporate compliance revealed nearly all of the same findings from the tour.

In an interview on 05/30/2023 at 4:15 p.m. S1Adm stated the hospital was under a plan of correction mainly for physical environment issues from Joint Commission 12/2022 and the hospital was in their window for a follow up survey.

In an interview on 05/31/2023 at 3:15 p.m. S2DON verified the above findings and verified the findings during the tour had not been corrected since the EOC and Life Safety Review dated 06/10/2022.

Based on observation and interview, the hospital failed to ensure that the life safety from fire requirement are met as evidence by; 1) Fire extinguisher located near unit 2 nurses station was not accessible; 2) Five illuminated Exit signs were missing from unit 2.

Findings:

1) Fire extinguisher located near unit 2 nurses station was not accessible.
On 05/25/2023 during the tour of the hospital at observation of the wall mounted fire extinguisher near unit 2's nurses station revealed the door to the extinguisher was pushed in and severly dented. S3RN attempted to open the door to access the fire extinguisher and she was not able to open the door and access the fire extinguisher.

In an interview on 05/31/2023 at 10:32 a.m. S3RN verified the fire extinguisher located on unit 2 near the nurse's station was not accessible by staff.

2) Five illuminated Exit signs were missing from unit 2 with capped wiring, which could be reached by patients.

An observation on 05/31/2023 at 10:35 a.m. of unit 2 revealed 5 missing illuminated Exit signs with the base and capped wiring which was within reach of patients.

In an interview on 05/30/2023 at 10:35 a.m. S2DON verified the Exit signs were missing and stated a patient had broken the Exit signs about two weeks prior and the wiring was accessible by patients who were tall enough to reach. She also verified she did not know if the wires had electricity flowing to them.

In an interview on 05/31/2023 at 12:20 p.m. S1Adm verified the missing Exit signs were ordered on 05/31/2023 at 12:21 p.m.

Based on observation and interview, the facility failed to ensure each patient room had an exterior window that conformed to state and federal regulations. This deficient practice is evidenced by opaque coverings on the windows in patient rooms prohibiting transmission of natural light and completely prohibiting patients from viewing the outside.

Findings:

Tour of the facility on 05/30/2023 between 9:15 a.m. and 11:30 a.m. revealed almost all patient rooms had an opaque covering installed over the windows with a small open area at the very top. The opaque coverings were white in some rooms and blue in other rooms and did not allow the patients to have view of the outside.

In interview on 05/30/2023 at 9:42 a.m., S1Adm and S2DON verified the opaque coverings prohibited the patients from being able to see outside. S1Adm and S2DON verified they were aware the patient rooms were required to have windows but were not aware the patients needed a view of the outside and state regulations required at least 12 square feet of clear glass.

Based on observation and interview, the hospital failed to maintain adequate temperature controls in patient rooms.

Findings:

An observation of patient room "P" on 05/31/2023 at 9:00 a.m. had a temperature of 86.9 degrees Fahrenheit with the air-conditioner on.

An observation of patient room "E"on 05/31/2023 at 9:20 a.m. had a temperature of 85.38 degrees Fahrenheit.

An observation of patient room `"F" on 05/31/2023 at 10:24 a.m. had a temperature of 90 degrees Fahrenheit.

An observation of patient room "G" on 05/31/2023 at 11:00 a.m. had a temperature of 85 degrees Fahrenheit.

In an interview on 05/31/2023 at 9:05 a.m. Patient #1 stated her room, Patient room "D" was hot, especially in the evening.

In an interview on 05/31/2023 at 9:25 a.m. Patient #2 verified her room as Patient Room "E" and also stated it was hot.

In an interview on 05/31/2023 at 10:25 a.m. Patient #3 stated Patient Room "F" was her room and it was hot.

In an interview on 05/31/2023 at 11:00 a.m. Patient #4 stated Patient Room "G" was his room and it was hot, especially in the evening.

In an interview on 05/31/2023 at 11:00 a.m. S2DON verified all the room temperatures and verified the individual air- conditioners were not able to cool the patient rooms adequately due to the metal enclosure around the air-conditioners. She also verified the patient room air-conditioners were on and operating.


In an interview on 05/31/2023 at 12:15 p.m. S1Adm verified the patient room air-conditioners were not able to adequately cool the patient rooms due to the metal enclosures and verified he was working on a quote for a new air-conditioner enclosures that would allow better air flow and cool the patient rooms adequately.

On a tour of the hospital on 06/15/2023 at 3:25 p.m. an observation of the following patient rooms revealed the following elevated temperatures in degrees Fahrenheit : Room "A" 88.5, "E" 87.1, "F" 87.4, "H" 85.0, "J" 87.2, "J" 87.7, "L" 88.1, "S" 84.7, "T" 86.1, "U" 85.3, and "V" 88.1.

In an interview on 06/15/2023 between 3:25 p.m. and 3:55 p.m. S6AdmAst verified the elevated temperatures in the patient rooms. She also said the building has been hot for a while and the patients all complain of the heat.

In an interview on 06/15/2023 at 3:15 p.m. with Patient #14 in room "F", he said it was extremely hot. He also said it was extremely uncomfortable.

In an interview on 06/15/2023 at 3:16 p.m. with Patient #15 in room "S", he said the heat was suffocating.

In an interview on 06/15/2023 at 3:58 p.m. with S7MHT, he said the whole building was hot and there were complaints by the staff and patients but nothing was being done.

In an interview on 06/15/2023 at 4:00 p.m. with S8MHT, she said the whole building was hot and the patients have been complaining.

In an interview on 06/15/2023 at 4:11 p.m. with Patient #9 in room "L", he stated that the room and hallways were extremely hot.

Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Infection Control. This was evidenced by the following findings throughout the facility: 1) dirty stained floors; 2) stained shower curtains; 3) showers with stained grout, missing caulk along edges, and poorly adhered panels; 4) handrails in the hallway with debris; 5) open food containers in patient rooms; 6) foam toilet seats with seams; 7) unfinished wood on door surfaces and bedside tables; 8) torn chairs and de-laminated countertop; 9) exterior door with rust like substance and furry growth in the door frame and grimy window sills; 10) patient restrooms with no soap or hand towels; 11) cracked leaking toilet in occupied room; 12) torn mattresses and pillows; and 13) linen not covered and on the floor. (See Findings Tag A0750)



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Based on observation an interview, the facility failed to ensure a clean and sanitary environment. The deficient practice is evidenced by the following findings throughout the facility: 1) dirty stained floors; 2) stained shower curtains; 3) showers with stained grout, missing caulk along edges, and poorly adhered panels; 4) handrails in the hallway with debris; 5) open food containers in patient rooms; 6) foam toilet seats with seams; 7) unfinished wood on door surfaces and bedside tables; 8) torn chairs and de-laminated countertop; 9) exterior door with rust like substance and furry growth in the door frame and grimy window sills; 10) patient restrooms with no soap or hand towels; 11) cracked leaking toilet in occupied room; 12) torn mattresses and pillows; and 13) linen not covered and on the floor.

Findings:

On 05/31/2023 between 9:15 a.m. and 11:30 a.m. a tour of the facility was performed and revealed the following:

1) Dirty stained floors observed throughout the facility.

Direct observation during tour of the facility revealed the floors were stained and had debris stuck to the floor. There was notable buildup of debris in corners and at the base of the door frames.

During the tour, S2DON verified the floor need to be cleaned throughout the facility. S2DON also verified the floors in common room "B" were not clean although it was obvious they were recently mopped.

2) Stained shower curtains observed throughout the facility.

Direct observation during tour of the facility revealed nearly all shower curtains had heavy reddish brown staining in the lower quarter and brown spotting on the upper half of the shower curtains.

During the tour, S2DON verified the shower curtains were stained and presented an infection control issue.

3) Showers observed with stained grout, missing caulk along edges, and panels poorly adhered to the walls throughout the facility.

Direct observation during tour of the facility revealed the showers were in poor repair with pink and black staining of the grout, missing caulk with open areas along the edges, and shower panels that had been pulled away from the walls with open unsealed sheetrock and large openings behind the panels. The common showers on Unit 2 appeared to have been initially installed with baseboards which were removed and ridges of material were left on the tile shower walls.

During the tour, S2DON verified the showers need to be cleaned and repaired. S2DON verified the areas missing grout and poorly approximated could not be properly cleaned and presented an infection control issue.

4) Handrails in the hallway observed to contain debris and a small plastic bag.

Direct observation during tour of the facility revealed handrails with debris and a plastic bag in the area above the attachment to the wall.

Direct observation also revealed housekeeping wiping only the top surface of the rail, and not the area above the attachment to the wall.

During the tour, S2DON verified the handrails were not clean and patients used the area to put pieces of trash.

5) Open food containers observed in patient rooms.

Direct observation during tour of the facility revealed open containers of chips, cookies, plastic bags with whole and half eaten sandwiches, and empty juice cups throughout the patient rooms. There were also dead roaches noted in several rooms.

Direct observation also revealed staff on Unit 2 delivering snacks into the rooms of patients.

During the tour, S2DON verified the presence of food and open containers in the rooms. S2DON verified the patients are not supposed to store food in the rooms and verified the snacks are not supposed to be brought to the patient's in their rooms. S2DON verified the presence of dead roaches and verified the food in the rooms was attracting roaches.

6) Foam toilet seats with seams observed in patient restrooms with thread stitching creating opening for bodily contents to enter the foam.

Direct observation during tour of the facility revealed foam padded toilet seats with seams in Patient Rooms "J", "K", "W", "Y", and "Z".

During the tour, S2DON verified the seats were an infection control issue and tears in the seats or leaks in the seams could allow urine to collect in the foam.

7) Unfinished wood present on door surfaces and bedside tables which cannot effectively be cleaned creating an infection control issue.

Direct observation during tour of the facility revealed unfinished wood on several doors to the Patient Rooms "Z", "BB", "C" and also on the doors to the restrooms. Several of the doors had splintered wood. The tour also revealed about half of the bedside tables in Patient Rooms "K", "W" were composed of bare wood without a sealant or clear coat.

During the tour, S2DON verified the wood was not finished on the doors and bedside tables and verified the wood was porous and could not be properly cleaned.

8) Torn chairs and de-laminated countertop present in common room "A".

Direct observation during tour of the facility revealed a countertop with missing laminate and two torn chairs in common room "A".

In interview during the tour on 05/30/2023 at 10:41 a.m., S4MHT verified the laminate was missing and the chairs were torn.

9) Exterior door present with rust like substance and furry growth in the door frame and grimy window sills.

Direct observation during tour of the facility revealed a rust like substance and furry growth in the frame of an exterior door on Unit 2. Further observation revealed a grimy substance on the ledge below the window to the common room "B" and grime on the window sills in the bedrooms throughout the facility.

During the tour, S2DON verified the exterior door was near a hole in the wall and had a moisture problem. S2DON also verified the grimy substance in the seal of the window to commonroom "B" and the grime on the window sills needed to be cleaned.

10) Patient restrooms observed with no soap or hand towels.

Direct observation during tour of the facility revealed none of the restrooms in the patient rooms had hand towels or soap in the wall dispensers.

During the tour, S2DON verified the paper towel dispensers and soap dispensers were not filled.

11) Cracked leaking toilet present in restroom associated with an occupied patient room.

Tour of patient room "C" revealed there were 2 occupants in the room. Observation of the associated restroom revealed a cracked leaking toilet.

During the tour at the time of discovery, S2DON verified the toilet was cracked and leaking.

12) Torn mattresses and pillows observed on patient beds and in use in the facility.

Direct observation during tour of the facility revealed a torn mattress in Patient Rooms "X", "AA" and a torn pillow in Patient Room "AA".

During the tour at the time of discovery, S2DON verified the torn mattresses and pillows.

13) Linen not covered and on the floor.
On 05/30/2023 a direct observation of Unit 1 linen closet revealed the linen was uncovered and patient scrubs were noted on the floor.

In an interview at the time of the survey on 05/30/2023 at 11:35 a.m. S2DON verified the linen closet findings and verified it was an infection control issue.




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