Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a clean, safe, comfortable, and homelike environment across three nursing units, as evidenced by multiple observations and interviews. In one instance, a resident reported that his mattress was peeling, and he was collecting the peeling material. Observations revealed several issues, including stained ceiling tiles, missing restroom mirrors, and baseboards, as well as a large brown substance spilled on the floor. Additionally, a hole in the ceiling tile and a broken sanitizer were noted, along with a urine odor in one room. The Maintenance Director confirmed these observations, which also included broken baseboards and peeling drywall. Further deficiencies were noted in the dining services, where residents were served meals on paper plates and drinks in Styrofoam cups due to a shortage of proper dining ware. This resulted in a sticky mess for one resident when a Styrofoam cup leaked. The Food Service Director confirmed the use of Styrofoam cups due to a shortage of coffee mugs, affecting the last unit served. These observations indicate a failure to maintain a homelike environment as per the facility's policy.
Plan Of Correction
1. Room 414 mattress replaced. Room 414 ceiling tiles replaced. 413 mirror in restroom hung up. 413 added baseboards to bottom of wall in restroom. 404 picture that was not hung was removed from room. 404 cleaned up substance on floor. 409 replaced ceiling tile. Removed broken sanitizer across from dayroom on 4th floor near 409. 409 cleaned. 418 fixed baseboard next to entrance. 418 fixed drywall. 312 fixed hole in bathroom wall and cleaned up drywall from bathroom floor. Items needed for kitchen to allow not to run out ordered. After 2nd floor R82 and R366 were served lunch on paper plates. 12nd floor R1 served thickened juice in Styrofoam cup. Test tray was served with coffee in Styrofoam cup. 2nd floor R141 and R111 served coffee in Styrofoam cups. 2. Audit of the whole facility completed that includes: - Mattresses - Ceiling tiles - Unhung items - Missing mirrors in bathroom - Missing / damaged baseboards - Dirty floors - Sanitizers - Odor smelly - Drywall damage To identify any additional items that need to be repaired. Audit / count of current dining needs including cups and plates and order what is needed. 3. Educate: - All nursing care staff to notify Maintenance / Administration of any mattresses that need repair/replacement/smelly, along with any rooms that have items in that need addressing. - Educate Maintenance Staff that rounding should include all areas noted: - Ceiling tiles - Unhung items - Missing mirrors - Damaged baseboards - Dirty floors - Sanitizers need replacement - Odorous rooms - Drywall damage. - All staff educated that using paper products is not part of a homelike environment and need to be avoided for this reason as well as for safety. Administration must be notified if there is a need to use paper products. 4. Random audits by the Administrator/designee to ensure that Maintenance Rounds are being completed on the whole facility, items being added to work list and work list is being worked on once a week for one month, twice a week for one month, and once a month for one month. Random audits by the Administrator/designee to ensure that paper products are being avoided to promote homelike environment and safety once a week for one month, twice a week for one month, and once a month for one month. The findings of the audits will be brought to the Quality monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.