Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of its nursing units, specifically the Main 1 and fifth floor units. Observations revealed several deficiencies, including a black plastic fan in a resident's room that was covered in a dark grey fuzzy substance, which remained uncleaned despite being reported to housekeeping. Additionally, multiple chairs in the Main 1 TV lounge and dining room were found with dried liquid spills, debris, and some had cracked or ripped cushions. A medical pump and pole in a resident's room were covered in a dried liquid substance, and the resident's wheelchair had an accumulation of dried food and debris. Further observations noted that another resident's bedroom floor was dusty and had a dark buildup around the edges, and a dresser in a resident's room had labels with names that did not match any current residents. Interviews with staff, including the Assistant Nursing Home Administrator and the Director of Nursing, confirmed awareness of these issues and acknowledged that the conditions did not meet the facility's expectations for cleanliness and maintenance.
Plan Of Correction
This provided submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1. Resident 338 had her fan cleaned of all dark grey fuzzy substances. M1 TV Room had all chairs cleaned so all spill stains and any debris on cushions and frames were removed. Three chairs were also removed off the unit because the cushions were cracked or ripped. Resident 178 had her medical pump and pole removed from the room and the feet of the pole was cleaned. M1 Dining Room chairs were cleaned and are free of any spills, stains and debris from the cushions and the frames. Resident 178 wheelchair was cleaned and is free of any dried food and debris. Resident 47 wheelchair was cleaned and is free of any dried food and debris. Resident 120 floor in their room was cleaned from dust/grit and is now free of any dark build up on the edges of the walls and furniture. Resident 327 dresser had all labels removed from the drawers that did not bear the name of the resident. 2. To identify other residents that have the potential to be affected, the NHA/designee completed an observational audit on all floors to ensure the following: a. TV and Dining Room chairs are free from cracks and tears as well as to ensure the chair cushions and frames are free of spills, stains or debris. b. Resident floors are free of dust and grit and that wall edges and furniture is free of dark spots. c. Resident rooms do not have unused medical poles in them and that the medical pole are clean. d. Resident wheelchairs are free of dried food and debris. e. Resident dressers are free of any labels that are not of the residents in the room. f. Resident personal fans are free of any fuzzy substances. 3. Staff will be educated by staff development/ designee on a clean and safe environment, wheel chair cleaning, general housekeeping and medical equipment cleaning. 4. The NHA/designee will conduct an observational audit on a random floor for 1x a week for five weeks to ensure: a. Resident fans are cleaned b. Chairs are clean and not damaged in the TV lounges and dining rooms c. That resident wheelchairs are cleaned of any dried food and debris d. Medical equipment that is not used is removed from room and clean e. Resident dressers do not have old resident labels on them and lastly to ensure resident floors are clean of any dust and debris as well as any dark spots on the wall edges and furniture. Results of the audits will be reviewed at the QAPI meeting to determine if future action/audits are needed.