Every finding on record at Garrett County Subacute Unit

Based on observations and interviews, it was determined that the facility failed to store food in accordance with professional standards. This deficient practice has the potential to affect all residents. The findings include: An initial tour of the facility's kitchen was conducted on 7/30/2025 at 9:53 AM with staff #9, the Director of Nutrition.Observation of the facility's walk-in coolers revealed the following:-An opened and almost finished buttermilk ranch dressing with a label dated 12/10/24. Staff stated that they received it on 12/10/24, but it should have been dated with an open and expiration date.-A Dusseldorf Mustard with a date on the container, 6/5/25. Staff #9 stated that the date on the container indicated when they received it, but it should have been labelled with an open and use-by date.-Banana pudding mix dated 7/28/25. Staff #9 stated that it was the preparation date and noted that it should have been labelled with a use-by date.-Chocolate pudding mix with a preparation date of 7/28/25, but had no use-by date.-Sour cream in a bowl lacked a use-by date.-Bagged provolone cheese, dated 7/29/25. Staff #9 stated that the date indicated was the preparation date; however, it lacked a use-by date.Further observation of the facility's walk-in freezer revealed an open bag of sausage links and an open bag of chicken tenders, both of which were missing their use-by dates.An interview later that day with staff #9 revealed that the facility's food labeling system had run out of labels. So, they had called the company, and it was on backorder. However, they had to use improvised labels, and their staff were inconsistent with their interim labeling process.

Based on record review and staff interviews, it was determined that the facility failed to ensure that staff were offered and educated about the COVID-19 vaccine. This was evident for four of five employee health files reviewed during the Infection Control task.Findings include:On 8/01/2025 at 1:59 PM, the surveyor reviewed staff immunization records and found that Staff #1, #5, #6, and the Director of Nursing (DON) were not offered or educated about the COVID-19 vaccine or most recent booster for 2024-2025.On 8/01/2025 at 2:31 PM, the surveyor interviewed the Nursing Home Administrator (NHA), who also serves as the facility DON. When asked whether staff were offered and educated about the COVID-19 vaccine or informed that it is an annual requirement, the NHA stated she was unaware of the requirement and confirmed that staff were neither educated nor offered the vaccine or booster. She advised the surveyor to confirm the process with the facility's Infection Preventionist Nurse (IPN #3).On 8/04/2025 at 1:20 PM, the surveyor interviewed IPN #3, who stated she was not aware that offering or educating staff about the COVID-19 vaccine and booster was a requirement. She further confirmed that the facility had not been offering or educating staff on the vaccine.On 8/04/2025 at 1:57 PM, the surveyor interviewed Staff #7, who is responsible for employee health. Staff #7 stated she was also unaware of the requirement to offer and educate staff regarding the COVID-19 vaccine and booster. She stated that the facility would adopt this process moving forward.On 8/05/2025 at 8:52 AM, the surveyor reviewed the facility's policy and procedure titled Employee Health Immunization Program (Policy V.032S, effective/reviewed on 6/20/2025), which stated in part: In accordance with WVUHS's (West Virginia University Health System) duty to provide and maintain a workplace that is free of known hazards, and consistent with guidance from CDC (Centers for Disease Control and Prevention) and other organizations, WVUHS adopts this policy to help safeguard the health of its Healthcare Workers (HCWs), their families, patients, clients, visitors, and the community at large from infectious diseases that may be reduced by vaccinations.Under General Guidelines:6.) COVID-19a) Vaccinate with 1 dose of an updated COVID-19 vaccine if HCW not up to date, and in accordance with current guidelines.

Based on record reviews and interviews, it was determined that the facility failed to 1). document the route of oxygen delivery each time a patient's oxygen saturation was documented. This was evident for 3 out of 3 residents (Resident #163, Resident #159, Resident #162) reviewed for Respiratory care and 2). failed to have hospice documentation in the medical recored. This was evident for 1 resident (Resident # 209) reviewed during an annual survey.The findings include: 1). On 3/16/23 at 8:37 AM, a review of medical records revealed that Resident #159 was admitted to the subacute unit on 3/6/23 for rehabilitation. Further review revealed a physician's order, dated 3/6/23, for the resident to receive oxygen 2 liters via nasal cannula when sleeping, and during the day when needed, to maintain an oxygen saturation level of 89%. A nasal cannula is a device designed to deliver oxygen directly to a patient's nose via a plastic tube that is tucked behind the ears and has two small soft flanges that aim for oxygen into the nostrils. Pulse oximetry is a technique of measuring the amount of oxygen in a patient's bloodstream (specifically peripheral capillary oxygen saturation, or 'SpO2') via a small device that is placed on the person's fingernail. The SpO2 measurement is given as a percentage. On 03/16/23 at 07:56 AM, a review of the vital signs that were recorded for Resident # 159 from 3/6/23 through 3/16/23 revealed that the pulse oximetry oxygen saturation was documented on the following dates and times: 3/6/23 at 21:30, 3/7/23 at 4:41 PM, 3/8/23 at 4:04, 3/9/23 at 4:11/23, 3/10/23 at 6:22 AM, 3/11/23 at 5:30 AM, 3/11/23 at 3:00 PM, Further review of the vital sign documentation for the above dates failed to reveal the route of oxygen delivery. On 03/16/23 at 08:27 AM, a review of medical records revealed that Resident # 169 was admitted to the subacute unit for rehabilitation on 3/8/23. Further review revealed a physician's order, dated 3/8/23, for the resident to be administered oxygen at 2/L via nasal cannula in order to maintain oxygen saturation rates above 89%. On 3/16/23 at 9:30 AM, a review of vital signs for Resident #169 from 3/11/23 through 3/15/23 revealed that the oxygen saturation was documented on the following dates and times: 3/11/23 at 3:00 PM, 3/12/23 at 7:08 PM., 3/13/23 at 3:59 PM, 3/14/23 at 3:45 PM, and 3/15/23 at 4:51 PM. Further review of the vital sign documentation for the above dates failed to reveal the route of oxygen delivery. On 03/16/23 at 09:12 AM, review of medical records revealed Resident # 162, was admitted to the subacute unit for rehabilitation on 3/10/23. Further review revealed a physician's orders for the resident to receive oxygen at a rate of 2/L nasal cannula to maintain oxygen saturation levels above 89 %. On 03/16/23 at 10:37 AM, a review of Resident #162's vital signs from 3/10/23 through 3/15/23 revealed that oxygen saturation was documented on the following dates and times: 3/10/23 at 4:00 PM. 3/11/23 at 3:00 PM, 3/13/23 at 3:59 PM, 3/14/23 at 5:30 AM, 3/15/23 at 5:30 AM. Further review of the vital sign documentation for the above dates failed to reveal the route of oxygen delivered. The Director of Nursing (DON) was interviewed on 03/16/23 at 08:07 AM. During the interview, she reported that the nurses are expected to document the route of oxygen administration, if the resident was receiving additional oxygen, and how much additional oxygen the resident was receiving every time the oxygen saturation level is documented. In addition, the DON reported that the subacute unit followed the Lippincott Procedures guide for the administration of oxygen. On 3/16/23, a review of the Lippincott Procedures Guide for the administration of oxygen revealed that documentation associated with oxygen administration should includes the type of delivery device( route). 31145 2) On 3/14/23 at 1:00 PM, Resident #209's medical record was reviewed. A 3/7/23 documented history and physical from Resident #209's attending physician revealed that Resident #209 was transferred from acute care to the subacute unit for hospice care on 03/06/23. Further review of Resident #209's medical record failed to reveal documentation of the care provided from the contracted company that was providing hospice services. On 3/14/23 at 1:30 PM, an interview was conducted with RN #4 and the Director of Nursing (DON) about what communication was in place between the subacute unit's staff and the hospice staff. RN #4 stated that hospice staff wouild meet with the subacute's unit staff after their encounter with the resident and verbally shared what they did, and would give any updates related to the resident's care. RN #4 stated that hospice had been in to care for the resident since the resident's admission. The surveyor informed RN #4 and the DON that the hospice notes were not found in the medical record. The DON stated that hospice staff documented the information in their own medical record system and that they shared a care plan, however, the hospice notes were not kept in Resident #209's medical record. On 3/16/23 at 9:28 AM, a second interview was conducted with the DON regarding the hospice notes. The DON confirmed the hospice notes should have been filed in the resident's medical record.

Based on observation and staff interview it was determined the facility failed to keep the walk-in freezer in the kitchen in safe operating condition. This was evident during the initial tour of the kitchen. The findings include: On 12/13/18 at 8:05 AM, during a tour of the kitchen with the Dietary Manager, observation was made of the walk-in freezer. There were ice formations on the ceiling in the freezer and under the 2 compressor fans. There was ice build-up on a bag of green beans and a box of cheese tortellini. There was a 2-inch-tall ice mound on top of a box of food which was located on the top shelf under the compressor fans. The Dietary Manager stated, we had that problem back in the summer and it is occurring again. I will have to call maintenance.

Based on medical record review and staff interview, it was determined the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 2 (#2, #4) of 5 residents reviewed for unnecessary medications. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. The findings include: 1) Review of the medical record for Resident #2 on 12/13/18 revealed a physician's history and physical, dated 11/5/18, which documented the assessment [DIAGNOSES REDACTED]. Review of the MDS assessment with an assessment reference date (ARD) of 11/14/18 and 11/21/18, Section I, diagnosis, failed to capture the diagnoses. Discussed with the Director of Nursing (DON) on 12/13/18 at 12:04 PM. 2) Review of the medical record for Resident #4 on 12/13/18 revealed a physician's history and physical, dated 11/22/18, which documented the assessment [DIAGNOSES REDACTED]. Review of the MDS with an ARD of 12/4/18, Section I, diagnosis, failed to capture the diagnoses. Discussed with the DON on 12/13/18 at 12:44 PM.

Based on medical record review, staff interview, and observation, it was determined the facility failed to develop comprehensive person-centered care plans with measurable goals. This was evident for 2 (#4, #5) of 5 residents reviewed for unnecessary medications. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1) Review of the medical record for Resident #5 on 12/13/18 revealed the resident was admitted to the unit 11/20/18 with an order for [REDACTED]. Review of care plans for Resident #5 failed to produce a care plan for the anticoagulant with specific interventions and measurable goals. Further review of the medical record revealed that Resident #5 took the pain medications [MEDICATION NAME] bitart/[MEDICATION NAME] ([MEDICATION NAME] 5/325) 3 times per day when needed for pain and Tylenol 650 mg. every 4 hours when needed for pain. Observation was made on 12/13/18 during medication administration of Resident #5 receiving medication. The nurse asked the resident if he/she had any pain and the resident replied he/she had pain on a scale of 6-8. The nurse gave the resident [MEDICATION NAME] for the pain. Review of care plans for Resident #5 revealed a care plan for pain, however, the goal was not measurable. Reviewed with the Director of Nursing on 12/13/18 at 9:57 AM. 2) Review of the medical record for Resident #4 on 12/13/18 revealed a physician's history and physical note, dated 11/22/18, which documented that the resident had uncontrolled Type 2 diabetes with complications. Review of Resident #4's (MONTH) (YEAR) physician orders [REDACTED]. Review of care plans created for Resident #4 failed to produce a specific, resident centered care plan for diabetes that had resident centered, measurable goals. This was discussed with the Director of Nursing on 12/13/18 at 12:44 PM.

Based on medical record review and staff interview, it was determined the facility failed to develop an individualized discharge plan/care plan for a resident admitted to the facility for short term rehabilitation. This was evident for 1 (#7) of 1 resident reviewed for discharge. The findings include: Review of the medical record for Resident #7 on 12/12/18 revealed documentation that the resident was admitted on [DATE] and discharged on [DATE]. Review of Resident #7's care plans failed to produce a care plan for discharge planning which would have identified the resident's person-centered discharge goals. Discussed with the Director of Nursing on 12/12/18 at 4:20 PM who confirmed the finding.

Based on observation and interview with staff,, it was determined that the facility staff failed to date and label food items. The findings include: Observation was made, on 12/13/18 8:05 AM, during a tour of kitchen with the Dietary Manager of the first walk-in refrigerator. Observation was made of a storage rack with 2 trays of pie/cheesecake. The tray on the top shelf had 10 slices of pie/cheesecake and the second shelf had a tray with 12 slices of pie/cheesecake. The slices were wrapped in saran wrap, however, the items were not labeled or dated. The Dietary Manager confirmed the findings.

Based on review of the medical record and staff interview, it was determined that the facility staff failed to monitor the effectiveness of as needed antianxiety medications. This was evident for 2 of 5 residents (#130 & #131) reviewed for unnecessary medications. The findings include: 1) Resident #130 had a physician's orders [REDACTED]. Review of Resident #130's Medication Administration Record [REDACTED]. Interview of the Director of Nursing (DON) on 9/5/17 at 4:20 PM revealed that there was no follow-up as to the effectiveness of the medication that the resident requested and received. 2) Resident #131 had a physician's orders [REDACTED]. Review of Resident #131's MAR indicated [REDACTED]. No monitoring of the effectiveness of the medication was found in the medical record. Interview of the DON on 9/5/17 at 4:20 PM confirmed this finding.

Based on review of employee files and staff interview, it was determined that the facility staff failed to maintain an effective Infection Control Program by failing to screen, test and immunize newly hired staff. This was evident for 3 of 6 employee files reviewed. The findings include: On 9/26/2016, a review of 6 employee health records of 6 facility employees hired during the previous 6 months revealed the following: 1) Geriatric Nursing Assistant (GNA) #2's Employee Health Medical Assessment Record form indicated no to the screening for [MEDICATION NAME] (Chicken Pox), [DIAGNOSES REDACTED] or[DIAGNOSES REDACTED]. Review of GNA #2's record and immunization history failed to provide proof of immunization to [DIAGNOSES REDACTED],[DIAGNOSES REDACTED], [DIAGNOSES REDACTED] (MMR) or [MEDICATION NAME]. The record also failed to provide evidence that a [MEDICATION NAME] titer had been done, and failed to show proof that a MMR titer was offered to determine immunity to these diseases. 2) Dietary Worker #1's Employee Health Medical Assessment Record indicated no to the screening for [DIAGNOSES REDACTED] and[DIAGNOSES REDACTED]. Review of Dietary Worker #1's record and immunization history did not provide proof of immunization to [DIAGNOSES REDACTED],[DIAGNOSES REDACTED], [DIAGNOSES REDACTED] (MMR) and did not show proof of immunization to Hepatitis B. The record indicated that Dietary Worker #1 was unsure if he/she had received the Hepatitis B Vaccine. The record failed to provide evidence that Dietary Worker #1 was offered a MMR and a Hepatitis B titer to determine immunity to these diseases. The record also failed to provide documentation that Dietary Worker #1 was offered the Hepatitis B Vaccine. 3) Environmental Service Worker #1 health record and immunization history indicated that he/she had not been immunized for Hepatitis B. Further review of Environmental Service Worker #1's record failed provide documented proof that he/she was offered the Hepatitis B vaccine. On 9/26/16 at 5:00 PM, the Infection Control Nurse was made aware of the employee health files reviewed and that evidence of titers, immunizations and Hepatitis B Vaccine declinations were missing from the records. When asked about the absence of documentation, the Infection control nurse stated that she knows that titers were done but needed to be filed and the surveyor should go in his/her office to see the papers that needed to be filed.

Based on observation during both stages of the Quality Indicator Survey and staff interview, it was determined the facility staff failed to write the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift per day on the daily staffing sheet for 1 of 1 nursing units. The findings include: On 9/26/16 at 9:30 AM, observation was made of the sub-acute unit daily staffing sheet. The total and actual number of hours worked by licensed and unlicensed direct care staff per shift per day was not listed. Additional observation was made on 9/26/16 at 2:00 PM of the sub-acute unit daily staffing sheet and the actual number of hours worked by licensed and unlicensed direct care staff was not documented. On 9/26/16 at 4:00 PM, the Nurse Manager was advised of these findings.

Based on review of medical record documentation and staff interview, it was determined the facility failed to ensure that Comprehensive Minimum Data Set (MDS) assessments were accurately coded. These concerns with inaccuracy were evident for 1 (#103) of 14 residents reviewed during Stage 2 of the Quality Indicator Survey. The findings include: The Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. At the end of the MDS assessment the interdisciplinary team develops a plan for the resident to obtain the optimal care. Review of the medical record revealed that Resident #103 had a skin tear which was assessed on 8/27/16. The skin tear measured 1.0 x 1.0 cm. A comprehensive admission MDS assessment, with an assessment reference date (ARD) of 9/8/16, failed to document that the resident had a skin tear and failed to document that a treatment/dressing was applied. The Unit Manager confirmed the finding on 9/26/16 at 2:30 PM, and stated that the resident was admitted with the skin tear.

Based on review of medical record documentation and staff interview, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. These concerns with inaccuracy were evident for 1 (#103) of 14 residents reviewed during Stage 2 of the Quality Indicator Survey. The findings include: The Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. At the end of the MDS assessment, the interdisciplinary team develops A plan of care for the resident to obtain the optimal care. Review of the medical record revealed that Resident #103 had a skin tear which was assessed on 8/27/16. The skin tear measured 1.0 x 1.0 cm. An MDS assessment with an assessment reference date (ARD) of 9/2/16 failed to document that the resident had a skin tear and failed to document that a treatment/dressing was applied. The Unit Manager confirmed the finding on 9/26/16 at 2:30 PM and stated that the resident was admitted with the skin tear.

Based on observations, it was determined the facility staff failed to date and label food items stored in the main kitchen. This was evident during an initial tour of the main kitchen. Findings include: An initial tour of the main kitchen was conducted with the Dietary Manager (DM) present on 9/26/16 at 10:00 AM, and the following concerns were identified: Inside of the freezer on the shelf were a bag of egg puffs, a bag of chicken breasts, and a bag of popcorn chicken that was opened and did not have a date label on the bag. Inside of the walk in refrigerator were 6 canisters containing the following food items; cubes of cut cheese, tomatoes, sliced pepperoni, broccoli, pineapples and peaches. The canisters did not have a date and label indicating when the items were prepared. The DM removed the food items from the refrigerator and the freezer. The Director of Nursing was made aware on 9/26/16 at 12:30 PM.

Based on observation it was determined that the facility staff failed to to have internal thermometers in 2 of 2 freezers observed, discard expired supplements in 1 of 1 dry storage areas, and properly label and cover food in 2 of 3 walk in refrigerator units. This was evident during the tour of the main kitchen. The findings include: On 4/14/14 at 1:05 PM a tour was conducted of the facility's main kitchen. Observation of the upright ice cream/desert freezer and the walk in freezer failed to reveal that they contained internal thermometers. In the dry storage room the surveyor observed: 1) 10 unopened eight ounce cans of [MEDICATION NAME] (a nutritional drink) with a manufacturers expiration date of April 1, 2014. 2) 5 unopened eight ounce drink boxes of Boost breeze (a nutritional drink) with a manufacturers use by date of April 10, 2014. Observation of the walk in refrigerator labeled cooler #3 revealed: 1) 1 opened five pound package of hot pepper jack sliced cheese approximately 1/3 full, wrapped in plastic wrap, not dated when opened. 2) 1 opened five pound package of sliced american cheese with approximately 1/6 having been used with not date as to when opened. 3) 1 opened plastic manufacturers bag labeled shredded parmesan cheese blend, almost empty rolled up and taped shut, not dated as to when it was opened. In the walk in refrigerator labeled cooler #1 the surveyor observed: 1) 1 opened five pound bag labeled sliced pepperoni and approximately 1/3 full. The bag had been rolled down and taped shut. It was not labeled as to when it was opened. 2) 2.5 loaves of marble bread, 4 bags of dinner rolls (each containing 24 and 1 bag containing 9), 4 bags of sub rolls (each containing 6 sub rolls), 1 bag containing 2 large pizza crusts. None of the bags were dated as to when they were received in the kitchen. 3) An uncovered metal steam table pan lined in plastic wrap containing sliced cooked white meat was on the top shelf immediately below the refrigerator compressor. There was no label as to it's contents or date. During an interview on 4/14/14 at 2:00 PM, the food service manager acklnowledged that he was aware of the meat on top the top shelf. He stated "that is how the county health department told me to cool food; cut it into smaller pieces, and place on top shelf of the refrigerator." When asked if he was instructed to leave it uncovered, he stated "yes". When asked about the missing in the freezers, he stated, "They should be in there, I don't know where they are". At that same time the undated food items were pointed out to him, and he confirmed that they should have been dated. The dietician was made aware of the above findings on 4/14/14 at 5:30 PM.

Based on medication administration observation during the survey, it was determined that the facility staff failed to ensure a medication error rate less than 5 percent for 4 out 7 residents (#84, 80, 81, 82) observed with 25 medications administered resulting in an error rate of 32%. The findings include: Observation was made on 4/14/14 at 4:02 PM of Resident #84 being offered the medication [MEDICATION NAME] 250 milligrams (mg). The instructions were to give twice per day with food. Resident #84 was also offered the medication Xarelto 10 mg (2) tablets. Resident #84 stated to Nurse #1 "I can't take these now. These have to be taken with food". Review of the Medication Administration Record [REDACTED]. During an interview with the unit manager on he Unit Manager stated on 4/14/14 at 5:20 PM she reported that the dinner trays do not come up until 5:30 PM. Observation was made on 4/14/14 at 4:26 PM of Resident #81, #82 and #80 each receiving the same 2 medications which were Thera-M Plus and [MEDICATION NAME] 325 mg. Both medications have the instructions written on the MAR indicated [REDACTED].

Based on observation it was determined that the facility did not maintain essential electrical equipment in safe operating condition by having a non NSF (National Sanitation Foundation) approved microwave oven in the main kitchen. The findings include: During the initial tour of the kitchen on 4/14/14 at 1:05 PM the surveyor observed an Emerson microwave oven. The microwave oven had a label on the back that identified it as for household use. It was not labeled for commercial use. The food service manager was made aware on 4/14/14 at 2:00 PM.

Based on record review and staff interview, it was determined that the facility failed to keep residents free from unnecessary drugs by failing to provide adequate indication for administration of prescribed pain relievers. This was evident for 1 of 5 (#79) residents reviewed for unnecessary drugs. The findings include: Review of resident #79's medical record on 4/14/14 at 3:45 PM, revealed that resident #79 was admitted after left knee arthroplasty surgery. The resident's record also revealed a physican's orders dated 04/05/14 stating: 1) [MEDICATION NAME]/[MEDICATION NAME] Bitart (a narcotic pain medication) 5/325(5 milligrams of [MEDICATION NAME]/325 milligrams of [MEDICATION NAME]) 1 tablet by mouth every 6 hours as needed not to exceed 4000 mg(milligrams) of [MEDICATION NAME] in a 24 hr period. 2) [MEDICATION NAME]/[MEDICATION NAME] Bitart 5/325 2 tablet by mouth every 6 hours as needed not to exceed 4000 mg of [MEDICATION NAME] in a 24 hr period. The physician's orders [REDACTED]. On 4/14/14 at 5:00 PM during an interview with employee #2, she stated she would know whether she should give 1 or 2 tablets of [MEDICATION NAME]/[MEDICATION NAME] by asking the resident if she needed 1 or 2 tablets. The DON(director of nursing) was made aware on 4/14/14 at 5:30 PM. After surveyor intervention, the physicians order was changed to indicate a pain level severity for each dose.

Based on surveyor observation, the staff failed to maintain the potential spread of infection The findings include: Based on surveyor observation during medication pass on March 21, 2012 at approximately 8 am, the facility staff (RN) opened a package containing aspirin 81mg. The pill dropped onto the medication cart. The RN picked up the pill with her ungloved hand placed the pill into the cup completed pouring the rest of the resident's (res. # 118) medication and administered the medication to the resident.

Based on surveyor observation, the staff failed to maintain proper handling of soiled laundry. The findings include: On January 24, 2011 at 6:50 am the surveyor observed the unit shower room door open. Contents in the room included wet towels and a sheet on the floor. The surveyor made nurse #1 aware of the concern. Approximately 5 minutes later a staff member on the unit took a laundry cart to the shower room and removed all soiled linens as well as cleaning up the room.