Deficiencies in Facility's Physical Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by several deficiencies observed during the survey. The shower room on the second floor had brown-colored matter on the floor, rust-colored stains on the wall above the grab bar, and black stains on the shower walls. Additionally, the paint on the floor was peeling in several areas. The first-floor shower room had gaps between the floor and walls, and both the floors and walls had black markings. The floor tiles on the south wing of the second floor were cracked in several places. Furthermore, a bed rail was observed with peeling paint and rust-colored staining, privacy curtains had black stains, and a blanket was found with holes. Photographic evidence was obtained to support these findings.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. **Physical Environment** A) What corrective action will be accomplished for those residents found to have been affected by this practice? a. On __, the second floor shower room was cleaned of brown colored matter. On the wall above the grab bar, as well as, the grab bar was removed of rust colored stains. On __, the black stains on the shower room walls were removed. On __, epoxy flooring project started by Custom Group, Inc., with an estimated completion date of __, to address the peeling paint on the floor of the shower stall. b. On __, epoxy flooring project started by Custom Group Inc., with an estimated completion date of __, to address the floor gaps and black markings in the first floor shower room stalls. On __, the black stains on the shower room walls were removed. c. On __, VCT material for floor tile repairs throughout the building were ordered. Commencement of work to be completed within 30 days of __ by Holiday Carpet Service. d. On __, the bed rails in __ were replaced. e. On __, privacy curtains in __ were replaced. f. On __, the blanket in __ was immediately replaced. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. On __, audit completed of the second floor shower room to ensure that it was clean, rust-free, and free of black stains on the walls. b. On __, audit completed of the first floor shower room to ensure that it was clean, rust-free, and free of black stains on the walls. c. On __, audit completed of floor tiles to identify cracks in floor tiles in need of repair. d. On __, audit completed of bed rails to ensure none had peeling paint with rust colored stains. e. On __, audit completed of privacy curtains to ensure curtains are free from stains. f. On __, audit completed of resident blankets to ensure blankets are in good condition. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. By __, the ED/designee educated the environmental services supervisor and maintenance director on ensuring that the facility shower room stalls, floors, and walls are maintained in good, clean condition. b. By __, the ED/designee educated the maintenance director on ensuring that cracks in floor tiles are repaired within a timely manner. c. By __, the ED/designee educated staff on identifying and timely reporting environmental concerns in TELS. D) How will the corrective actions be monitored to ensure the practice will not reoccur; what quality measures will be put into place? a. ED/designee to randomly audit shower rooms to ensure that they are clean and in good repair. b. ED/designee to randomly audit 6 resident rooms to ensure resident bed rails are rust-free, bedding is free of holes, and privacy curtains are in good, clean condition. c. ED/designee to randomly audit floor tiles to ensure tiles are in good condition. d. Audits will be conducted weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. Findings will be reported monthly at the QA/Risk management meeting until such time substantial compliance has been determined.