Facility Fails to Maintain Homelike Environment Due to Maintenance Issue
Penalty
Summary
The facility failed to maintain a homelike environment for one of the nine residents reviewed. Specifically, the baseboard heating system in Resident R5's room was observed to be detaching from the wall, creating a noticeable gap. This observation was made during a survey on December 22, 2024, at approximately 10:30 a.m. The facility's policy, dated November 8, 2024, mandates that housekeeping and maintenance services should ensure a sanitary, orderly, and comfortable environment. During an interview later that day, the Director of Nursing confirmed that the gap was not homelike and acknowledged that it should have been repaired or replaced.
Plan Of Correction
This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law. Twinbrook Healthcare has taken immediate corrective action to address the cited deficiency and ensure the facility provides a safe, clean, comfortable, and homelike environment for all residents. The gap between the baseboard heating system and the wall in Resident R5's room was repaired on 12/22/24. Additionally, a full-house audit was conducted by the Maintenance staff and was completed on the same day to verify that all baseboard heating systems throughout the facility were securely attached to the walls. No other issues were identified during this audit. To prevent recurrence, Twinbrook Healthcare has implemented an inspection process for all baseboard heating systems to check for proper attachment to walls to maintain a homelike environment to be completed weekly for two [2] weeks and monthly for two [2] months. These inspections will be conducted by the Maintenance Director or a designated staff member for a period of two months, with findings reviewed in Quality Assurance Performance Improvement (QAPI) meetings. Any identified issues will be addressed promptly. The Maintenance Director or designee will re-educate all staff on the facility's policy regarding reporting maintenance concerns, including the importance of promptly notifying the Maintenance Department of any issues affecting the safety, cleanliness, or comfort of the environment. Re-education sessions will be completed by 1/20/2025, and ongoing education will be provided during orientation for new hires and as part of regular staff training. Through these actions, Twinbrook Healthcare reaffirms its commitment to maintaining a high standard of living for its residents, ensuring their safety and comfort at all times. Full implementation of this Plan of Correction is completed by January 20, 2025.