Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for its residents, as observed during a recertification survey. Multiple deficiencies were noted across several units, including mismatched paint patches, discolored blinds, worn window treatments, torn wallpaper, damaged furniture, and dirty, dusty areas. These issues were evident in four out of five units, indicating a widespread problem with the facility's maintenance and housekeeping practices. On Unit 1 North, the baseboard and door corners in the shower room were in disrepair, and several rooms had large unpainted areas near the radiator. Unit 1 East had unpainted patches on hallway walls and ceilings, dirty windows, cracked plaster, missing privacy curtain hooks, and damaged walls. The 2nd Floor had mismatched paint, peeling paint, unpainted patches, tattered window treatments, and loose air conditioner units. Unit 1 West had stained and worn furniture, broken window blinds, dusty and dirty window sills, and broken plaster. Interviews with maintenance and housekeeping staff revealed that repairs and cleaning were not being completed in a timely manner. Maintenance workers acknowledged delays in painting and repairing damaged areas due to other priority assignments. Housekeepers reported challenges in cleaning certain areas due to resident presence and the inability to clean certain items effectively. The Director of Housekeeping and Maintenance and the Administrator acknowledged the issues and stated that efforts were being made to address them, but the deficiencies remained uncorrected at the time of the survey.
Plan Of Correction
Plan of Correction: Approved January 2, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** **Immediate Correction:** 1) As of 12/31/24, The Maintenance Department will prioritize the immediate repair of all areas identified in the survey, including the unpainted walls, mismatched paint patches, cracks, and damaged areas in Rooms 40, 38, 37 (Unit 1 North), Rooms 25, 28, 18, 16/17 (Unit 1 East), Rooms 206, 210, 203, 211, 215, 217 (2nd Floor), and Rooms W49, W65, W47b, W52 (Unit 1 West). 2) As of 12/31/24, All areas observed with visible dirt, dust, or staining (e.g., air conditioner units, windowsills, walls, and bathroom tiles) were thoroughly cleaned and sanitized by the Maintenance/Housekeeping team. 3) As of 12/31/24, the windows in room [ROOM NUMBER], the air conditioners in multiple rooms (e.g., W49b, W65), and the bathrooms with stained tiles were cleaned by the Maintenance/Housekeeping team. 4) As of 12/31/24, The Housekeeping staff performed a detailed cleaning of the affected areas and provided documentation of completion. 5) As of 12/31/24, In Room W49b, the stained and worn mattress, broken bed frame, and broken closet were repaired. 6) As of 12/31/24, The missing door handle in Room W49b was replaced by the Maintenance team. **Identification of Others:** 1) Units 1 North, 1 East, 2nd Floor, and 1 West will have their rooms assessed for cleanliness and safety, and corrective actions will be taken as needed. All affected rooms will be given priority for repairs and cleaning. 2) The Director of Housekeeping and Maintenance will oversee that the rooms are returned to a safe, clean, and comfortable environment. 3) A facility-wide audit will be conducted to identify any additional rooms or common areas that may require repair, cleaning, or redecoration. This includes assessing all floors, any unpainted walls, damaged window treatments, and necessary repairs to ensure that all areas meet the facility’s safety and comfort standards. **Systemic Changes:** 1) The facility’s Safe, Clean, Comfortable and Homelike Environment policy will be revised to include clearer guidelines on maintaining rooms, common areas, and the timely reporting of repairs or maintenance concerns. 2) The updated policy will also specify the roles and responsibilities of the Housekeeping and Maintenance departments in ensuring a safe and homelike environment. 3) The Director of Maintenance and Maintenance and housekeeping workers will undergo additional training to understand the updated standards and expectations for maintaining a safe, clean, and homelike environment. 4) A clear protocol will be implemented for housekeeping staff to immediately report issues to the Maintenance Director, including a system for tracking repairs and ensuring all issues are addressed in a timely manner. 5) The facility will implement daily environmental rounds with the Administrator, Assistant Administrator, Director of Housekeeping, and Maintenance Director to assess the cleanliness, safety, and comfort of resident rooms and common areas. 6) A formal audit checklist will be developed to ensure the environment meets the facility's standards for cleanliness, maintenance, and homelike qualities. 7) Any issues identified during the rounds will be documented, and corrective actions will be taken immediately. Any issues that cannot be resolved during the rounds will be logged and addressed within a defined timeframe (e.g., 24-72 hours). 8) A Maintenance Log will be implemented, where maintenance and housekeeping staff will be required to record and report any issues they notice during cleaning. This log will be reviewed daily by the Maintenance Director to ensure timely action is taken. 9) The facility will ensure all maintenance issues reported in the log are tracked through completion, with clear timelines for resolution and documentation. 10) Staff will be instructed to immediately report any areas of concern in resident rooms or common areas, ensuring that all repairs and cleanliness issues are promptly addressed. **Quality Assurance:** 1) The Director of Maintenance/Housekeeping will conduct weekly audits for the next 3 months to ensure that all repairs, cleaning, and updates have been completed as per the standards outlined in this plan. The audits will also assess whether the facility is maintaining a safe, clean, comfortable, and homelike environment for residents. 2) The facility administration will establish a feedback mechanism for residents and their families to provide input on the condition of the environment. A survey or comment box will be placed in common areas to allow for anonymous feedback on cleanliness, safety, and comfort. 3) Feedback will be reviewed by the Administrator and the QAPI team, and corrective actions will be taken based on the feedback received. 4) Weekly audits will be completed by the Maintenance and Housekeeping weekly x 4 weeks; monthly x 3 months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 5) Findings will be brought to the QAPI quarterly meeting for tracking of facility compliance. **Person Responsible for this Ftag:** 1) The Administrator.