Inadequate Temperature Control and Unsanitary Conditions in Shower Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment, as evidenced by inadequate housekeeping and maintenance services. Specifically, the air temperatures in the Harbor View unit were consistently below the required range of 71 to 81 degrees Fahrenheit, with temperatures recorded as low as 66.7 degrees Fahrenheit. Residents and staff reported feeling cold, with some residents wearing multiple blankets and winter clothing indoors. The maintenance staff acknowledged issues with the heating system, including thermostats set below the required temperature and obstructions affecting heat distribution. Additionally, the facility did not adhere to its cleaning and disinfecting policies, resulting in unsanitary conditions in the shower rooms on the City View and Harbor View units. Observations revealed dried brown debris, identified as feces, on shower floors and chairs, which were not cleaned between uses. Staff interviews confirmed that the responsibility for cleaning was not consistently followed, leading to potential infection control issues and a failure to provide a homelike environment. The facility's policies on maintaining a homelike environment and cleaning procedures were not effectively implemented, contributing to the deficiencies observed. Staff members, including CNAs and housekeeping aides, were unclear about their responsibilities, resulting in inadequate cleaning and maintenance practices. The Director of Nursing and other management staff acknowledged the issues but did not ensure compliance with established protocols, leading to the observed deficiencies.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 Maintenance adjusted the thermostat in Resident Rooms #136 and #133. Maintenance also adjusted the thermostat that controls the common area on Harbor View and City View units. The shower chair and shower room floor on the City View unit and Harbor View unit were cleaned and disinfected per policy. The equipment was removed from the stall. An audit was conducted to ensure the temperatures in other areas of the facility are within a range of 71 degrees to 81 degrees Fahrenheit. All shower rooms on all other units in the facility were checked to ensure shower equipment and shower rooms were clean; no other areas of concern were identified. The maintenance director and maintenance staff were educated on maintaining the temperature in the facility rooms within the range of 71 degrees to 81 degrees Fahrenheit. All CNA staff will be educated on the policy/procedure for cleaning and disinfecting reusable items between resident use. All housekeeping staff will be educated regarding the policy/procedure for cleaning shower rooms. The maintenance director will audit one unit for temperatures weekly for 4 weeks, then monthly for 3 months, including 4 resident rooms. The DON/Designee will audit shower room shareable equipment on one unit to ensure that they are clean and without debris/bodily fluids weekly for 4 weeks, then monthly for 3 months. The Director of Housekeeping will audit one unit's shower rooms to ensure floors are clean and without debris/bodily fluids weekly for 4 weeks, then monthly for 3 months. Audit findings will be reported to the QAPI committee for review. Responsible Person: DON