Deficiencies in Safe and Homelike Environment
Penalty
Summary
Valley Manor Rehabilitation and Healthcare Center was found to be non-compliant with the requirements for providing a safe, clean, comfortable, and homelike environment as per 42 CFR Part 483, Subpart B. During the survey conducted on March 4, 2024, several deficiencies were observed across multiple rooms in the facility's Central nursing unit. These included broken fixtures, such as a doorknob in room 103 and a closet door in room 209, as well as missing amenities like paper towels in room 103. Additionally, numerous rooms had walls that were heavily marred with chipped paint, including rooms 105, 106, 107, 111, 113, 201, 202, 209, 211, 213, and 215. Other issues included window curtains being off the rod in rooms 106, 202, and 211, and privacy curtains stained in room 211. Structural problems were also noted, such as a large hole along the baseboard in room 201, broken and missing tiles in rooms 213 and 215, and closet doors peeling and separating in rooms 107, 209, and 213. These observations indicate a failure to maintain the facility in a manner that ensures a safe and comfortable environment for residents, as required by federal and state regulations.
Plan Of Correction
1. Rooms were addressed during the visit. 2. The maintenance Director and Housekeeping Director will conduct environmental rounds together to ensure room issues are rectified and addressed. 3. The maintenance director will create a painting schedule for each room and coordinate with nursing and housekeeping until completion. Housekeeping will provide deep clean/target room schedules. Staff will be educated on utilizing maintenance work order forms to report any issues identified. Maintenance director will address work order forms as received. 4. Administrator or designee will conduct weekly audits on room rounds to ensure progress is being made in rooms and issues corrected. Data will be reviewed at QAPI.