Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment as observed during the recertification and abbreviated surveys. In the shower room on the 3A unit, there were black stains on the shower curtain, brown discoloration on the tiles at the base of the toilet, and black and orange stains on the tile grout in the shower stall. Additionally, a window air conditioner caused a cold draft in the room. Resident #18 reported the shower room was cold and had mildew. The Director of Housekeeping acknowledged that the shower curtain should have been replaced and the tiles needed cleaning, but they had not received any reports about these conditions. The Director of Maintenance was unaware of the issues but acknowledged the need for addressing the grout discoloration and the draft caused by the air conditioner. In another incident, soiled linens were found on the floor next to Resident #27's bed. A Certified Nurse Aide confirmed that soiled linens should be bagged and placed in a linen hamper, not on the floor. Additionally, a broken handrail with a sharp edge was observed at the entrance to the 3A dining room. The Maintenance Worker and the Director of Maintenance were not aware of the broken handrail, but the Director of Maintenance stated that handrails would be added to the list of items to check during rounds.
Plan Of Correction
Plan of Correction: Approved March 21, 2025 F 584 Safe/ Clean/ Comfortable Homelike Environment I. Immediate Corrections: - The Housekeeping staff cleaned the Shower room on unit 3A. The black and orange dis-coloration along the base of the shower stall was removed. Completed 2/26/2025. - The Housekeeping staff cleaned shower curtains. Black stains on the bottom of curtain were removed. Completed 2/25/2025. - The Housekeeping staff cleaned the toilet. Discolored brown stains on tiles around the base of toilet were removed. Completed 2/26/2025. - The window air conditioner unit that was allowing cold draft to enter the shower stall was removed by the maintenance staff. Completed 2/26/2025. - The Certified Nursing Assistant picked up the soiled linen with feces that was next to the bed in Resident # 27 room. The Linen was bagged and placed in hamper. Completed 2/20/2025. - The broken handrail on the right side of the dining room entrance was repaired by the maintenance staff. Completed 2/26/2025. II. Plan of Correction to identify other areas potentially affected - The facility acknowledges that all residents have the potential to be affected by this practice. - The Director of Plant Operations will inspect all areas throughout the facility for same deficiencies. Any deficiencies found will be scheduled for correction. Completed 2/28/2025. III. Systemic Changes - All maintenance staff, housekeeping and nursing will receive additional education, and all participants will understand the requirements of providing a Safe, Clean, Comfortable, and Homelike Environment for residents in compliance with 483.10. The Director of Plant Operations and Staff Development has been assigned responsibility for the education of staff. - The Policy & Procedures were reviewed, and it was determined that no changes to the policy were necessary. IV. Quality Assurance Monitoring - The Director of Plant Operations/Housekeeping will conduct audits on all rooms to ensure a homelike environment is maintained weekly x 4 weeks and then monthly for 3 months unless any significant trends are identified. Any concerns during audits will be addressed immediately to ensure compliance with standards of care or practice. - The Director of Plant Operations or Designee will review monthly audits for any cases of non-compliance. The Director of Plant Operations or Designee will report the result of these audits to the QAPI committee on a monthly basis, as well as correction plan if warranted. Responsibility: Director of Plant Operations