Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe and homelike environment in the Milestone Unit, as evidenced by multiple observations of physical damage in resident rooms. On January 28, 2025, during an observation of the Milestone Unit, surveyors noted significant damage to the walls in rooms 21, 22, and 23. Room 23 had two holes in the wall by the window, measuring 3.0 x 5.0 inches and 2.0 x 5.0 inches. Room 22 had one hole measuring 5.0 x 7.0 inches, and room 21 had two holes measuring 2.0 x 11 inches and 2.0 x 2.0 inches. These observations were still present during a follow-up observation on January 31, 2025, indicating a lack of timely maintenance and repair. An interview with Employee E3 on January 31, 2025, revealed that the employee was unaware of the holes in the walls of rooms 21, 22, and 23, suggesting a communication breakdown or oversight in reporting and addressing maintenance issues. The findings were discussed with the Nursing Home Administrator on the same day, highlighting the facility's failure to maintain a safe and homelike environment as required by federal and state regulations.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. 1. Facility failed to provide a safe and homelike environment in the Milestones unit in rooms 21, 22, and 23. Holes were repaired in rooms 21, 22, and 23. 2. Audit of all resident rooms in Milestones unit completed to ensure no other areas were observed. 3. Maintenance Director/Designee will complete training of staff on the components of this regulation to include the need to report all changes in environment to maintenance. 4. The Maintenance Director/Designee will complete audits of 5 rooms 2 x a week x 4 weeks, then 1 x a week x 4 weeks, then 2 x a month, then 1 x a month x 2 months to ensure that all rooms have a safe homelike environment. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings in QAPI. 5. Date of compliance will be 2/28/25.