Environmental Deficiencies in Resident Units
Penalty
Summary
The facility was found to have deficiencies in maintaining a safe, clean, comfortable, and homelike environment for residents in several units. Observations revealed multiple issues such as missing paint, unpainted patched holes, missing door thresholds, and accumulated dirt and debris in resident rooms across Units 2 North, 2 South, and 3 South. Additionally, the 2 South dining room lacked homelike decorations. These conditions were contrary to the facility's policies on resident rights and quality of life, which emphasize providing a dignified and homelike environment. Interviews with staff, including registered nurses, certified nurse aides, housekeepers, and maintenance personnel, indicated a lack of awareness and communication regarding the environmental issues. Staff members were expected to enter work orders for maintenance issues, but many were unaware of the existing problems or did not know how to use the work order system effectively. The Director of Housekeeping and Laundry noted that some housekeepers left handwritten notes instead of using the computerized system, and the Director of Maintenance stated that most work orders were completed within 24 hours, although there were no outstanding orders for missing thresholds. The facility's failure to address these environmental deficiencies was evident in the numerous open work orders and the lack of timely maintenance. The presence of dirty linens on the floor, missing thresholds, and unpainted areas contributed to an environment that was not homelike and posed potential tripping hazards. Staff interviews highlighted a disconnect between identifying issues and ensuring they were reported and resolved, leading to ongoing deficiencies in the facility's environment.
Plan Of Correction
Plan of Correction: Approved February 10, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - 272B: Paint scrap behind the head of bed - 265B: Paint unpainted plaster - 225: Put in floor tile, paint near bathroom sink, put in door threshold - 220: Put in floor tile outside door, paint wall, put in door threshold - 206: Put in door threshold, pick-up and clean dirty linen and trash in room - 203: Put in door threshold, clean trash - 202: Clean sticky yellow spot at base of bed on the floor - 201: Put in door threshold 2 South Dining Room: repair hole in wall near floor, paint under television, paint unpatched patch on right side, add personalization to dining room with wall decals and colored paint, and picture frames 3 South Supply Closet: Add molding to doorknob side 3 South Nurses Station: Paint door scratch behind nurses station 305: Paint door jam frame paint chips The facility will identify other residents having the potential to be affected by the same deficient practice and the following corrective action will be taken - Audit all units for homelike environment: All resident areas The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur - Education on homelike environment to maintenance and housekeeping departments The corrective action(s) will be monitored to ensure the deficient practice will not recur: - Audit Resident areas on units for homelike environment x1 Month for 3 consistent months at 100%. The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Director of Maintenance