Facility Fails to Maintain Safe and Homelike Environment Due to Maintenance Oversight
Penalty
Summary
The facility failed to provide a safe, sanitary, and homelike environment for residents on Unit 1, as evidenced by damage to drywall and chair rails in 8 out of 31 rooms. Observations during an initial tour revealed that the drywall and chair-rails behind residents' beds in rooms 6, 9, 14, 18, 21, 35, 37, and 39 were damaged, with chair-rails found on the floor. Additionally, holes were observed in the drywall next to the bathroom doors in rooms 6, 9, 14, 21, and 39. A resident reported that the damage had been present for several months and that staff had been informed, but no repairs had been made. The facility had been without a full-time Maintenance Director for several months, and the newly hired Maintenance Director confirmed the damage during a tour. The Maintenance Director noted that the damage was not documented in the facility's maintenance computer system as required by their Work Orders policy. The Administrator confirmed the absence of a full-time Maintenance Director and acknowledged that the responsibilities of the Maintenance Director included ensuring minor repairs and supervising day-to-day maintenance to prevent deterioration of the facility's physical condition.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. # ,18,21,35,37,39 findings were fixed and addressed. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: A. A Complete audit of all room was conducted, and findings were noted and put on a schedule to be completed. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: A. Staff was educated on the TELS system. B. Facility Maintenance department and the staff was educated on the components of F584. C. The Maintenance director will check the TELS system daily. D. During morning meeting any environmental concerns will be relayed. E. Department heads concierge rounds were added to report any environmental concerns. F. Education on the components of F584 will be provided annually and upon new hires. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Nursing Home Administrator/Designee will audit the Tels system for timely resolution of work orders along with random room rounds to ensure adequate safe environment is maintained weekly for four weeks then monthly for one quarter. The Nursing Home Administrator/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.