Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of deficiencies across various units. Resident rooms were found with scratched and damaged furniture, mismatched paint, holes in drywall, and duct tape on floors. Additionally, enteral feeding pumps and poles were observed with cream-colored stains, and shared bathrooms and whirlpool tubs were noted to be dirty and in disrepair. The kitchen area also exhibited several issues, including leaking kettles, cracked tiles, and grease residue on metal shelves. Interviews with staff revealed that maintenance and cleaning protocols were not consistently followed or effectively communicated. Dietary aides reported broken kitchen tiles and leaking kettles, while housekeeping staff were unsure of reporting procedures for damaged furniture. Maintenance staff acknowledged the need for repairs and replacements but indicated that matching paint and replacement doors were still pending. The Director of Maintenance confirmed ongoing remodeling efforts but did not provide specific timelines for completion. The facility's policies on cleaning and disinfecting resident care items and equipment were not adequately implemented, as evidenced by dusty and stained medical equipment and furniture. Staff interviews highlighted a lack of clarity regarding cleaning responsibilities and the frequency of maintenance checks. Despite some efforts to address these issues, the facility's environment remained substandard, compromising the residents' right to a homelike and safe living space.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** **F584 Element 1 Immediate Corrective Action:** The Maintenance Director and Food Service Director immediately took action to correct the deficiencies identified in the kitchen. A 1/2-inch quick valve was replaced to correct the leak on the kettle. The Quarry floor tile has been ordered, and all cracked kitchen tiles will be replaced throughout the kitchen. The gap in the wall edge by refrigerator #3 will be repaired. Metal shelving in the kitchen holding washed dishes was immediately cleaned. Cracked flooring and baseboard tiles in the dish room were replaced. The cracked floor tile identified in freezer #2 has been removed and will be replaced with quick-dry cement and epoxy. Next, work will begin on Refrigerator #1, and the floor will be replaced. The dish room handwashing sink opening has been closed in the tile surrounding the pipe. The metal stairs identified by the compactor were replaced on (MONTH) 14, 2025, and the wheelchair parts stored were removed. The Housekeeping and Maintenance Directors immediately acted to correct the deficiencies identified in the nursing units. **2 East:** The Director of Housekeeping audited to ensure that all feeding pumps were cleaned. Any pumps with stains, including E209, W203, and W238, were immediately cleaned or replaced. In E206, the floor tile was replaced, the duct tape was removed, and the garbage can was replaced with a new one. The drywall on the elevator bank on 2 East elevators #1, #2, and #3 was repaired and replaced with corner guards. The fan was cleaned and removed. **2 East:** The 3 areas identified with a gap around the piping in the shower rooms under the sink were filled, the shower drain cleaned, and the drain cover replaced. All debris noted in the century tub was removed and cleaned. Hoyer canvas was removed for routine cleaning. The Director of Maintenance did a whole house audit to ensure all a/c units were clean and dust-free. Areas identified were immediately cleaned to include the following rooms: W238, W203, W208, E318, E302, E311, E308, E315, E306, E302, E317, and the 4 units on 4 West Dayroom. **2 West Medication Room:** The company who built the cabinets was contacted to replace the peeling veneer on the upper middle cabinet door. The kitchenette and refrigerator/freezer in the staff lounge were cleaned immediately. **2 W room [ROOM NUMBER]:** The call light box was replaced on the wall. **room [ROOM NUMBER]:** The chip noted in the barn door was filled in, and the door was repainted. The medication cart on 2 West was removed and cleaned. **2 West Main shower room:** Debris identified in the century tub was removed, and the tub was cleaned. The bariatric shower chair was removed and cleaned, and any rusty wheels will be replaced. The cracked tile under the sink was replaced. The sharps container on the Wound Care Cart was adhered correctly to the cart to ensure it was closing. **2 West Lobby Area:** The baseboard heater cover had fallen off and was clipped back on. The ice machine vent was cleaned immediately. The hole in the wall behind the refrigerator was repaired, and the gap between the fridge and the false pantry will be repaired as we proceed. **3 East:** Brookstone Developers will begin renovating the following rooms starting (MONTH) 20, 2025: 3 East Rooms 300, 318, 306, 339, 303, 311, 308, 317, 309, 315, 305, 304, 302, 308. This will include replacing ceiling tiles and grids, flooring, painting walls, nightstands, overbed tables, wardrobe closets, a handwashing sink inside resident rooms, and new tile and showers inside each resident's bathroom. **3 West:** Brookstone Developers completed the renovation of the 3 West Main Shower Room and removed the Century Tub. This renovation includes new ceiling tiles, lighting and grids, fixtures, tile, and flooring. All old equipment, such as commodes, has been discarded. **Pantry:** All areas within the pantry were cleaned, and the metal ladle in the drawer under the microwave was discarded. **3 West Medication carts:** In (MONTH) 2023, Specialty Pharmacy provided Crown Heights Center with new medication carts; each unit has 2 medication carts and 1 treatment cart. The housekeeping department schedules the monthly cleaning of medication carts using a pressure washer. During this process, the Director of Housekeeping will in-service the staff to clean the bottom of the medication cart. All medication carts identified as being dusty or soiled were immediately cleaned. **4 West:** The 4th-floor hallway and the opposite side of the elevators were repainted. Room [ROOM NUMBER] was completely renovated and painted. W 417 Resident Room chair was replaced. The 5 Tier Linen cart with a cracked left edge was repaired. Bedside tables will be replaced in the following rooms: W400, 414, 406, 403, 408, 407, 409, 417, 421, 432, 428, 405. **Element 2 Residents at Risk:** All residents have the potential to be affected by this practice. The Food Service Director immediately audited all trays. Any cracked trays will be removed. The Director of Maintenance and the Director of Housekeeping conducted a visual inspection of the entire facility, and no other issues were identified. **Element 3 Systemic changes:** Policies and procedures were reviewed, and no revisions were necessary. On (MONTH) 6, 7, and 8th, maintenance and housekeeping staff were in-serviced to maintain a safe, clean, and comfortable environment. The housekeeping director is responsible for ensuring all equipment is clean and operable. The director of maintenance is responsible for ensuring preventative environmental rounds are routinely conducted and any identified issues are corrected immediately. An audit tool has been developed to monitor compliance. **Element 4 Monitoring of Corrective Action:** On a weekly basis for 6 months, Maintenance and Housekeeping directors will conduct environmental audits. The maintenance and housekeeping director will report findings to the administrator monthly. Any issues identified will be corrected as soon as possible. Maintenance and housekeeping directors will report findings to the QAPI Committee for two quarters. The QAPI Committee will determine if any further action is required. **Element 5 Responsibility:** Director of Maintenance, Housekeeping Director, and the Administrator.