Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by multiple deficiencies observed during the recertification survey. On the third floor, the exhaust ventilation was non-functional in several areas, including the staff bathroom, resident bathrooms, and the soiled utility room, resulting in significant foul odors. The Maintenance Director acknowledged the issue, citing difficulties in securing an electrician for repairs. Additionally, a resident room had a damaged wall and a missing drawer, while two sit-to-stand lifts were found heavily soiled with brown residue and debris. Further observations revealed that three chairs in the second-floor dining room were in disrepair, with chipped and cracked surfaces and damaged cushions and armrests. The microwave oven in the second-floor clean utility room was heavily soiled with food splatter. The first-floor south exit stairwell was cluttered with spiderwebs and dead bugs, and the exit discharge door had a significant gap, compromising its fit. In another resident room, duct tape and heat tape around the windows were peeling, allowing cold air to enter, and a section of the wall was cracked and peeling.
Plan Of Correction
Plan of Correction: Approved February 7, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. All identified issues have been addressed, specifically: 1. The exhaust ventilation on the third floor was fixed. 2. The damaged wall behind the resident bed in room [ROOM NUMBER] was repaired. 3. Two sit-to-stand lifts outside resident rooms #201 and #219 were cleaned. 4. Five new chairs were ordered to replace the three chairs that were chipped, cracked, and had damaged cushions and armrests. 5. The microwave oven in the second-floor clean utility room with heavily soiled interior was replaced. 6. The spiderwebs and dead bugs on the first floor south exit stairwell were removed. 7. The gap below and around the lower edge of the exit discharge door from the first floor leading to the back parking lot was repaired. 8. The windows in resident room [ROOM NUMBER] were re-taped around the edges of the window to prevent cold air coming through. Also, the damaged wall behind the bed closet was repaired. 2. All residents have the potential to be affected. The facility will conduct a full building audit to ensure all exhaust ventilations are functioning correctly, any damaged walls in resident rooms are repaired, all chairs used by residents are not chipped or damaged, all microwave ovens in clean utility rooms are clean, all stairwells are free of spiderwebs or dead bugs, all exit doors have tight fitting, and resident windows are appropriately heat taped. The maintenance department and the administrator were educated on the importance of maintaining a homelike environment, to continuously round the facility to identify deficient areas, and to immediately address identified areas. An audit tool will be utilized to randomly audit 3 rooms for homelike environment to ensure compliance. 3. The facility will randomly audit 3 rooms for homelike environment weekly x 4 weeks then monthly x 3 months. Identified issues will be immediately addressed. Results of the audits will be brought to the QAPI meeting for review. The Director of Maintenance is the responsible party.