Deficiencies in Housekeeping and Maintenance
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment as required by regulations. Observations revealed several deficiencies in housekeeping and maintenance across multiple resident hallways and common areas. In particular, a resident reported a broken window air conditioner that had not been addressed since their admission, and another resident's room had stained privacy curtains and an unpleasant odor. Additionally, the over-the-bed table for another resident was rusted, and a recliner was worn and uncleanable. A resident also noted a longstanding plaster issue on their wall. The Housekeeping Director acknowledged the issues but indicated that the deep cleaning schedule did not include the affected rooms, and the Maintenance Director admitted to being the sole maintenance person, which delayed repairs. Further observations in the common areas and hallways revealed dirty and rust-like substances on ceiling vents, as well as bubbling and peeling paint on walls. The Maintenance Director confirmed these findings but noted that the maintenance book lacked entries for the current year, indicating a lack of documented maintenance activities. The report highlights the facility's failure to ensure timely housekeeping and maintenance, affecting the living conditions of several residents.
Plan Of Correction
N-110 Safe/Clean/Homelike Environment 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Ceiling vents have been corrected. Ceiling vents on 100, 200, 300 and 400 Halis, and in the central common area have been removed, sanded & repainted to an acceptable condition, and then replaced in their proper slots. This was completed on. All areas of bubbling and peeling paint were repaired and repainted in Hall 300 and Hall 400, as of. Resident # 42 privacy curtains were replaced with new clean curtains on 3/, and privacy curtains will be examined daily and changed daily, or as needed. Resident # 42 baseboard behind bed was replaced with new, as of. Resident # 42 A new bed was provided to this resident as of. Resident # 42 Floor was sanitized and cleaned on, and this room is inspected daily and will be cleaned daily or as needed. Resident # 23 A new overbed table was provided for this resident, as of. Resident # 23 The recliner was removed from this resident's room, as of. Resident # 66 The wall behind the bed was repaired to an acceptable condition as of. Resident # 244 A new Air Conditioner has been installed in this room, on. Resident #42: room where this resident resides has been added to the 'target list' of rooms that are inspected every day. (2) How will you identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Maintenance & Housekeeping Department Heads will incorporate a weekly resident room inspection at the beginning of the week. These inspections will be documented and discussed upon completion to identify areas of concern. Findings will be addressed and corrected depending on the severity & impact on the residents. Inspections for the room inhabited by resident #42 will be daily. The resident uses the privacy curtains to wipe himself when using the bathroom. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Maintenance & Housekeeping staff have been made aware of the additional weekly inspections. All other staff members have been re-educated regarding reporting maintenance & housekeeping issues in the maintenance logbooks posted at the nurse's stations. All staff members have also been instructed to verbalize their requests, when possible, in addition to noting them in the maintenance logs. All staff members have been educated on the escalation process should they feel an environmental issue has not been addressed. Daily inspections of the 'target rooms' list will continue ongoing. Facility staff were educated by the Executive Director/Designee on ensuring a safe, clean, homelike environment, and how to report concerns for maintenance and environmental services. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The Maintenance & Housekeeping Departments will conduct a weekly efficiency & quality review of the additional maintenance and housekeeping inspections & reporting process x 4 weeks, and then every 2 weeks x 2 months then PRN as indicated. The findings of these quality reviews are to be reported to the Quality Assurance/Performance Improvement Committee monthly x 3 months, or until the committee determines substantial compliance. The Administrator/Designee will conduct a quality review of resident rooms, kitchen, to ensure facility is providing safe, clean and comfortable homelike environment 3 times weekly x 4, then weekly x 4 weeks, then monthly x 1 month and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 3 months or until substantial compliance is maintained.