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F0584
E

Facility Fails to Address Maintenance Issues Promptly

Norristown, Pennsylvania Survey Completed on 12-09-2024

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a safe, clean, comfortable, and homelike environment for nine residents, as evidenced by multiple unresolved maintenance issues. The facility's policy, "Environment of Care," requires that work orders be prioritized and addressed in a timely manner, but this was not adhered to. Several work orders, including those for malfunctioning toilets, beds, and call bells, were left open and unresolved for extended periods, impacting the residents' ability to receive care and services safely. Resident R1 and R2 experienced issues with a non-flushing and overflowing toilet in their room, which was reported on November 16, 2024, but remained unresolved as of December 9, 2024. Resident R1 also reported a malfunctioning bed that was not addressed promptly, leading to a room change. Similarly, Resident R9 had a mattress issue reported on December 3, 2024, which was only resolved six days later. Residents R7 and R8 had a non-functioning call bell, and they were only provided with hand-held bells on the day of the survey. Additional unresolved issues included a leaking ceiling in Resident R5's room, reported on September 16, 2024, and a broken call light in the room of Residents R3 and R4, reported on November 15, 2024. The Maintenance Director confirmed that these work orders were not addressed in a timely manner, indicating a systemic failure in the facility's maintenance processes, which compromised the residents' safety and comfort.

Plan Of Correction

1. The toilets in room 128 and in the 2nd floor north side shower room have been repaired. Rooms 018 and 024 call bell has been repaired. Missing ceiling tile in room 003 has been replaced. 2. Maintenance director/designee will audit all current open work order requests to ensure they are addressed timely. 3. Administrator/designee will reeducate Maintenance director on ensuring work order requests are addressed timely. 4. Maintenance director/designee will conduct audits of all new work order request to ensure timely completion, weekly X4 monthly X 3. Finding will be presented to QAPI Quarterly X 2.

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