Facility Environment Deficiencies
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment across all four nursing units observed, namely A-Wing, B-Wing, C-Wing, and D-Wing. Observations revealed that in the D-Wing, the wall trim behind a resident's bed was falling off, and wallpaper was peeling away in multiple rooms on both the D-Wing and C-Wing. These conditions were confirmed by staff interviews, indicating a lack of maintenance and attention to the physical environment of the residents' rooms. Additionally, the nurses' stations across all wings were found to have broken chairs, which were uncomfortable and difficult for staff to use for essential tasks such as charting and phone calls. The C-Wing nurses' station also had phones that were either broken or had worn-out numbers, making communication challenging. Staff interviews corroborated these findings, highlighting the discomfort and difficulty in performing their duties due to the poor condition of the furniture and equipment.
Plan Of Correction
Room 216 D wing wall trim has been repaired. Room 214 D wing wall has been repaired. Room 215 C wing wall paper has been repaired. Office chairs have been ordered for all of the wings. C wing phones have been replaced. Maintenance will complete an initial audit of all the rooms for needed repairs to the walls. Maintenance will audit all of the office chairs in the nursing units and order replacement for the damaged/broken chairs. NPE will re-educate staff to add all repair needs to TELS system. NHA/designee will conduct weekly audits x2 and monthly x1 to ensure compliance. Maintenance Director will report the findings of the audits to the QAPI Committee X 3 months.