Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents in the North 2 unit, as observed during a recertification survey. Specific deficiencies included broken tiles in rooms X6 and X3, a cracked wall in room V1, and a hanging curtain in room S3. Additionally, the shower room had a damaged drain, and the hallway window near room V3 was left open, causing a resident to complain of feeling cold despite the room thermometer reading 74 degrees. The Maintenance Director acknowledged ongoing renovations and issues with the shower drain, attributing the problem to the weight of some residents. Interviews with staff revealed a lack of awareness regarding the open hallway window, with certified nurse aides and a registered nurse unable to identify who opened it. The registered nurse suggested it might have been opened for fresh air after care was provided but acknowledged it should have been closed. The absence of a documented work order logbook for repairs further highlighted the facility's failure to maintain a homelike environment, as required by regulations.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 All Residents, Visitors, and staff have the potential to be affected by the deficient practice. On 2/12/2025, the Director of Environmental Services or designee repaired the curtain in room S3. On 2/12/2025, the Director of Environmental Services or designee patched the crack by the window in room X1. On 2/14/2025, the Director of Environmental Services or designee locked the windows on the corridor where V3 window is located to ensure that the window does not open and V3 does not get a draft. On 2/12/2025, the Director of Environmental Services or designee affixed the tiles in room X3 where they were coming loose. On 2/12/2025, the Director of Environmental Services or designee patched the scuffs under the window in room V1. On 2/14/2025, the Director of Environmental Services or designee hired a company to replace the floor in room X6. On 2/12/2025, the Director of Environmental Services or designee permanently affixed the drain cover to the north 2 shower drain. The Director of Environmental Services or designee will conduct monthly checks for 6 months in rooms S3, X1, X3, X6, V1, V3, and the shower room to ensure that the repairs that were made continue to hold their integrity. All findings will be discussed during QAPI.