Deficiencies in Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents in 9 out of 64 rooms. Observations revealed various deficiencies, including stained flooring and walls, disrepair of baseboards, and stained privacy curtains. In one instance, a resident's privacy curtain did not adequately cover the window area, and another resident's dresser drawer was broken. Additionally, a TV was connected to a power strip, which could pose a safety risk. The environmental tour further identified strong odors in some rooms, blackened baseboards, and soft bathroom walls with unsmooth plaster. Interviews with residents and staff confirmed these environmental concerns. The Environmental Services Representative acknowledged that the baseboards had been painted over and that the paint comes off during cleaning and buffing. They mentioned a plan to replace all room baseboards and flooring, pending tile delivery. Despite these plans, the current state of the facility did not meet the regulatory requirements for a safe and homelike environment, as evidenced by the observations and resident feedback.
Plan Of Correction
SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of flooring, wall and baseboard behind residents bed where stained and in disrepair. Maintenance/Housekeeping staff will fix, and or clean flooring, wall and baseboard behind resident's bed. 2) In the allegation of privacy curtain stained, floor stained and baseboard in disrepair. Maintenance/Housekeeping staff will change privacy curtain, fix, and or clean flooring, wall and baseboard behind resident's bed. 3) In the allegation of bathroom light dim and blinking and baseboard behind resident's bed in disrepair. Maintenance/Housekeeping staff will change or fix the bathroom light, and or clean/fix baseboard behind resident's bed. 4) In the allegation of privacy curtain does not cover window area. Maintenance staff will fix or replace privacy curtain to ensure it covers the window area. 5) In the allegation of wall outside of room in disrepair, broken dresser drawer, power strip for the TV. Maintenance staff will repair the wall outside of the room, they will fix or place the dresser drawer, and they will remove the power strip from the TV. 6) In the allegation of baseboard in disrepair and floor stained behind residents nightstand and bed. Maintenance/Housekeeping staff will fix, and or clean flooring, and baseboard behind resident's bed and nightstand. 7) In the allegation strong-like odor in bathroom, room baseboards blackened, bathroom wall near the door soft and plaster not smooth. Maintenance/Housekeeping staff will clean the bathroom to remove the -like odor, baseboards will be repaired or replaced, and the wall will be repaired and smoothed out. 8) In the allegation of strong -like odor. Housekeeping will scrub and clean rooms to remove -like odor. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: - Maintenance/Housekeeping staff will fix, and or clean flooring, wall and baseboard behind resident's bed. - Maintenance/Housekeeping staff will change privacy curtain, fix, and or clean flooring, wall and baseboard behind resident's bed. - Maintenance/Housekeeping staff will change or fix the bathroom light, and or clean/fix baseboard behind resident's bed. - Maintenance staff will fix or replace privacy curtain to ensure it covers the window area. - Maintenance staff will repair the wall outside of the room, they will fix or place the dresser drawer, and they will remove the power strip from the TV. - Maintenance/Housekeeping staff will fix, and or clean flooring, and baseboard behind resident's bed and nightstand. - Maintenance/Housekeeping staff will clean the bathroom to remove the -like odor, baseboards will be repaired or replaced, and the wall will be repaired and smoothed out. - Housekeeping will scrub and clean rooms to remove -like odor. Random QA audits will be conducted by the Director of Maintenance or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 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 into place: Random QA audit will be conducted by the Director of Maintenance or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee for a period of three months and until substantial compliance is met.