Deficiency in Maintaining a Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents in four out of five rooms observed. Specifically, rooms 301, 302, 303, and 304 on the third floor unit exhibited issues such as missing ceiling tiles and leaking stains on ceiling tiles. In room 301, a missing ceiling tile and six leaking stains were observed in the restroom, along with a leaking stain down the wall. Room 302 had leaking stains on ceiling tiles above the resident's bed, while room 304 had a missing ceiling tile and three leaking stains. Room 303 also had leaking stains on two ceiling tiles. An interview with a resident in room 304 revealed that the missing ceiling tile between beds A and B had been absent for about a week, with no observed efforts to replace it. The facility's policy on maintaining a safe, clean, and homelike environment, revised in April 2022, was not adhered to, as evidenced by the lack of housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. These observations and resident feedback indicate a failure to meet the regulatory requirements for a homelike environment.
Plan Of Correction
1) Missing and stained ceiling tiles will be replaced in rooms 301, 302, 303, and 304. 2) House wide auditing will be conducted in resident care areas to ensure there are no missing or stained tiles. Tiles will be replaced as needed. 3) Current housekeeping staff will be re-educated on replacing stained and missing ceiling tiles and conducting routine auditing during daily cleaning routine. 4) Maint. Director or designee will do random audits weekly X4 and monthly X2 for missing and/or stained ceiling tiles and replace them as necessary. Results will be reviewed monthly in QAPI and determined if further auditing is necessary.