Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment as required by regulations. Observations during an initial tour of Unit 1 revealed drywall damage and broken chair rails in several resident rooms, specifically rooms 18, 21, 35, 37, and 39. Holes were also noted in the drywall next to the bathroom doors in rooms 21 and 39. A resident reported that the chair rail molding behind beds had been damaged for several months and that staff had been informed, but no repairs had been made. The facility had been without a full-time Maintenance Director for several months, and the newly hired Maintenance Director confirmed the damage during a tour. The Maintenance Director also noted that the damage was not documented in the facility's maintenance computer system as required by their policy. The Administrator confirmed the absence of a full-time Maintenance Director and acknowledged the responsibility of the Maintenance Director to ensure minor repairs and day-to-day maintenance to prevent deterioration of the facility's physical condition.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. # 18,21,35,37,39 findings were fixed and addressed. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. A Complete audit of all room was conducted, and findings were noted and put on a schedule to be completed. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur; A. Staff was educated on the TELS system. B. Facility Maintenance department and the staff was educated on the components of F584. C. The Maintenance director will check the TEL.S system daily. D. During morning meeting any environmental concerns will be relayed. Department heads concierge rounds were added to report any environmental concerns. E. Education on the components of F584 will be provided annually and upon new hires. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Nursing Home Administrator/Designee will audit the Tels system for timely resolution of work orders along with random room rounds to ensure adequate safe environment is maintained weekly for four weeks then monthly for one quarter. The Nursing Home Administrator/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.