Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for residents on both the South Wing and North Wing. Observations revealed multiple deficiencies across various rooms. In room 120, the walls were heavily marred, while room 121 had marred walls and a closet missing both doors. Room 123 also had a closet missing both doors. In room 125 bed H, a fan was found with a heavy accumulation of dust and dirt. Room 127's bathroom had a broken floor tile in front of the toilet and a water-stained ceiling tile. Room 129 and room 131 had heavily marred walls, with room 131 also having a large hole in the drywall and a water-stained ceiling tile in the bathroom. Additional issues were noted in other rooms: room 133 had a windowsill covered with dirt and debris, and the wallpaper was peeling behind bed W. Room 134 bed W had a broken dresser drawer handle. Room 135's ptac unit contained debris and dirt, and the bathroom floor was buckled. In room 137 bed W, a solid black thick substance was splattered on the floor. Room 98's bathroom had a brown stain along the bottom molding and a black-stained floor tile. Room 116 had an accumulation of dust in the window corner and on the curtain. Lastly, room 109 had a layer of floor material lifted away from the base in the entryway.
Plan Of Correction
1. The fan in room 125, bed H, has been cleaned and dusted by the housekeeping staff. Housekeeping staff also cleaned the windowsill in room 133, the PTAC unit (ductless air conditioning unit) in room 135, the solid black substance in room 137, bed W, and the dust on the window and curtain in room 116. Room 123 had the closet doors replaced. Room 134 bed W the dresser drawer handle was repaired. Room 127 had the tile repaired and the ceiling tile replaced. Room 131 had the ceiling tile replaced. Room 133 had the wallpaper reglued to the wall. Rooms 120, 121, 129, and 131 will have marred walls repaired. Room 131 will have the hole repaired. Room 135 will have the bathroom floor redone. Room 98's bathroom wall and floor will be repaired. Room 109's floor will be replaced in the area that was lifted away from the base. 2. The maintenance director and housekeeping director will conduct a building wide audit of walls, closet doors, floors and furniture for areas of repair needed. 3. The housekeeping director will reeducate housekeeping staff on maintaining standards of cleanliness of the building. 4. Maintenance director and Housekeeping director will conduct weekly audits of walls, closet doors, floors, and furniture in resident rooms for areas that need repaired x 8 weeks, then monthly x2. Audits will be reviewed at the QAPI meeting for review or recommendations.