Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment, as evidenced by observations made by a surveyor. On December 3, 2024, in the St. [NAME] hallway, linen including towels and blankets were found unfolded and piled onto the outside handle of the linen cart. Additionally, in the St. [NAME] Soiled Utility room, linens were observed overflowing and not bagged from the receptacle, with two trash bags placed on top of the trash receptacle. In the St. Mary's soiled utility room, linens in untied trash bags were left on the floor. During an interview on December 4, 2024, the Infection Preventionist acknowledged that soiled utility rooms should not be piled up and confirmed that she ensures nothing is on the floor. On December 5, 2024, the Licensed Nursing Home Administrator (LNHA) stated that soiled utility rooms are checked twice during the day shift, but additional checks by housekeeping were requested. The LNHA confirmed that trash bags should be in receptacles and not on the floor.
Plan Of Correction
Plan of Correction F584 Level D Completion Date: 1/15/2025 Corrective Action: Linen found outside of the linen cart was placed in soiled laundry. Linens in the Soiled Utility Room were tied, taken off the floor and placed in the receptacle. Soiled linen was removed from Soiled Utility Room. ID Other Residents: Any resident within the facility Systemic Change: In-service Proper Storage of Linens will be given to the Nursing Department and Laundry by Nurse Educator completed by 1/15/2025. In-service Proper Disposal of Soiled Linens will be given to the Nursing Staff and Laundry by Nurse Educator completed by 1/15/2025. Soiled linens will be collected by laundry service 3 xs daily on the morning shift and 2 xs daily on the evening shift. Additional laundry disposal bins will be purchased to handle the amount of soiled linen that is created. Monitoring: Audit - Clean and Soiled Linen will be completed on the following schedule: (4) weekly xos 2 weeks then (4) monthly xos 2 months then (4) quarterly x 1 quarter by Infection Preventionist. Audit Soiled Utility Room Linen Disposal will be completed on the following schedule: (4) weekly xos 2 weeks then (4) monthly xs 2 months then (4) quarterly x 1 quarter by Infection Preventionist. Results of the audits will be brought to QA/QAPI on a quarterly basis xos 3 quarters.