Deficiency in Maintaining a Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple observations of unsanitary conditions and maintenance issues. On Units 1 and 5, surveyors observed brown stained ceiling tiles in both hallways and resident rooms, indicating potential water leaks. The Environmental Department Director acknowledged awareness of the leaks and the need for roof replacement but was not informed about specific stained tiles in resident rooms. This lack of communication and action contributed to the ongoing issue of stained and potentially moldy ceiling tiles, which were not addressed promptly. In Unit 5's Resident Spa, surveyors noted a strong fecal odor, soiled wet linens on the floor, and a soiled shower curtain over several days. Certified Nurse Aide #5 and the Director of Housekeeping confirmed that aides were responsible for removing soiled linens and bodily fluids, while housekeepers were to sanitize the area. However, the persistent unsanitary conditions indicated a failure in executing these responsibilities, leading to an infection control issue as highlighted by the Infection Preventionist. Additionally, the baseboards in Unit 5's hallways were observed to be dirty with dark debris, contributing to an unclean and unhomelike environment. Staff interviews revealed dissatisfaction with the cleanliness and maintenance of the facility, with reports of sticky floors and concerns from family members about the facility's state. The Administrator acknowledged the need for clearer job duties and recognized the leaking roof as a problem, but the ongoing issues with cleanliness and maintenance were not adequately addressed, resulting in a deficiency in providing a homelike environment.
Plan Of Correction
Plan of Correction: Approved January 6, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident room [ROOM NUMBER] had four ceiling tiles replaced by maintenance. Unit 1 hall ceiling tiles were replaced. Wallpaper was removed where damaged by maintenance. Resident room [ROOM NUMBER] ceiling tiles were replaced by maintenance. Resident spa on Unit 5 was sanitized by housekeeping. Unit 5 hallways were sanitized by housekeeping. Baseboards were cleaned by housekeeping. Hallway floors were stripped and waxed by Floor tech. The Roof will be reviewed in Spring 2025 for roof repairs. 2. All residents are at risk for deficient practice of facility not being homelike as evidenced by sticky unclean floors, soiled ceiling tiles, dirty showers. 3. An Audit of all shower rooms was conducted by EVS Director and all shower rooms were sanitized. An Audit was completed of all ceiling tiles in the facility and any deficient practice was corrected. An Audit of all baseboards was completed and baseboards were cleaned by floor tech. 4. Administrator reviewed the policy and procedure on floor care, daily housekeeping care, and ceiling tiles. New policies were created for the facility. Administrator reviewed the policy and procedure for ceiling tiles; no changes were made. The Outside consultant will educate all staff on reporting environmental concerns including soiled ceiling tiles, cleaning issues in showers, and floors. 5. Administrator educated EVS Director on floor care and daily housekeeping. All Housekeepers were educated on floor care and daily housekeeping. Administrator reviewed P and P on ceiling tile replacement with Maintenance Director. 6. QA Members will conduct weekly rounds for 6 months on floor care, ceiling tiles, and shower room cleaning. Any deficient practices will be corrected immediately and brought to QAPI for further review. Resident grievances will be reviewed monthly for environmental concerns. Any deficient practices will be corrected immediately. Person Responsible: EVS Director