Facility Fails to Maintain Sanitary and Functional Environment
Penalty
Summary
The facility failed to maintain a clean, orderly, functional, and sanitary environment for its residents, as observed during a recertification survey. In one instance, a room had no hot water supply for approximately three weeks after a sink replacement. Residents in this room had to use a bathing room across the hallway to access hot water, which was inconvenient, especially during winter. Despite the maintenance department's records indicating the sink was reinstalled and in working condition, there was no documentation of the hot water issue in the maintenance book. Interviews with staff revealed a lack of communication and follow-up regarding the hot water problem, with several staff members assuming others had reported the issue. Additionally, several rooms and common areas were found in disrepair, with issues such as deep scratches on walls, broken tiles, and dust accumulation. The shared shower room on Unit 3 had broken tiles, a missing shower head clamp, and a brownish to black substance in the corners. The maintenance logs did not reflect these issues, and staff interviews indicated a lack of awareness and reporting of these environmental problems. The Director of Housekeeping and Maintenance stated that rounds are conducted weekly, but the issues observed during the survey were not documented or addressed. The 2nd Floor Unit also had multiple deficiencies, including cracked window screens, debris in air conditioning/heater units, and peeling baseboards. Flies were observed in the dining room and hallway, and there were white granules and black stains in the dining room pantry. Maintenance staff indicated that repairs are only made when work orders are submitted, and there was a lack of proactive identification and resolution of environmental issues. The Director of Plant Operations and Maintenance mentioned that rounds are conducted weekly, but the observed deficiencies were not addressed in a timely manner.
Plan Of Correction
Plan of Correction: Approved January 31, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F584 483.10 Safe/Clean/Comfortable/Homelike Environment SS=E I. The following actions were accomplished for the resident(s) identified in the sample: 1. The facility engaged a certified plumber to permanently repair the hot water to the sink in room [ROOM NUMBER]. Completed 1/9/25. 2. The maintenance staff repaired and painted the wall scratches in the wall behind the bed and behind the door in room [ROOM NUMBER]. Completed 1/23/25. The maintenance staff replaced the headboard on the bed in room [ROOM NUMBER]. Completed 1/26/25. The maintenance staff will repair the identified panel molding in room [ROOM NUMBER]. Completed on 1/30/25. In Unit 3 Shared Shower Room, the maintenance staff permanently repaired the broken yellow tiles. Completed 1/8/25. The maintenance staff will replace the shower hose holder assembly and replace the changed stained ceiling tiles. Completed 1/27/25. The housekeeping staff completed a deep cleaning of the shower walls, floors, and the identified screen. Completed 1/8/25. 3. A. The maintenance staff will replace the identified window screen in the 2nd floor Dining Room. Completed on 1/30/25. B. The housekeeping staff cleaned the items from within the HVAC unit in room [ROOM NUMBER]. Completed 1/8/25. The maintenance staff will repair or replace the identified cove base in room [ROOM NUMBER]. Completed on 1/30/25. C. The housekeeping staff cleaned the items from within the HVAC unit in room [ROOM NUMBER]. Completed 1/8/25. The maintenance staff will repair or replace the identified cove base and repair and paint the damaged wall in room [ROOM NUMBER]. Completed on 1/30/25. D. The maintenance staff replaced the footboard on the bed in room [ROOM NUMBER]. Completed 1/26/25. Maintenance repaired the bathroom pipe faucet dripping and left faucet not closing to stop water from dripping. Completed 1/24/25. E. The maintenance staff will repair or replace the identified cove base, repair and paint the damaged wall (Completed on 1/30/25), and repaired the leaking sink faucet in room [ROOM NUMBER]. Completed 1/8/25. F. The maintenance staff will replace the window screen in room [ROOM NUMBER]. Completed on 1/30/25. The housekeeping staff removed the two round items from the top of the HVAC unit. Completed 1/8/25. G. The maintenance staff will replace damaged window screens on the 2nd floor. Completed on 1/30/25. The Director of Plant Operations contacted the facility's pest control vendor to provide a mitigation plan for flies. Mitigation plan and implementation was completed on 1/30/25. H. The housekeeping staff cleaned the 2nd floor Dining Room Pantry shelves and cabinets. Completed 1/24/25. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Maintenance will inspect all areas throughout the facility for the same deficiencies. Any deficiencies found will be scheduled for correction. III. The following system changes will be implemented to ensure continuing compliance with regulations: All maintenance staff, housekeeping, and nursing will receive additional education, and all participants will understand the requirements of providing a Safe, Clean, Comfortable, and Homelike Environment for residents in compliance with 483.10. The Director of Plant Operations and Staff Development has been assigned responsibility for the education of staff, and the Director of Plant Operations will report the findings to the QAPI Committee for the period of six (6) months. The Policy & Procedures will be reviewed and updated to include that all staff must report issues promptly in the maintenance log. Resident safety issues must be immediately reported to a supervisor in addition to the maintenance log. The Director of Plant Operations/Housekeeping will conduct weekly rounds to identify maintenance and housekeeping issues. The Director of Plant Operations/Housekeeping will each complete documentation of the weekly rounds in an audit tool and report the findings to the QAPI Committee monthly for a period of six (6) months. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The Director of Plant Operations or Designee will review monthly audits for any cases of non-compliance. The Director of Plant Operations or Designee will report the result of these audits to the QAPI committee on a monthly basis, as well as the correction plan if warranted. Responsibility: The Director of Plant Operations/Designee will be responsible for compliance.