Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, and homelike environment in two resident rooms, specifically rooms #201 and #214. In room #201, a resident reported that the dark brown armoire's drawer was broken and could not be opened, which had been an issue for some time. The observation confirmed that the face of the top drawer was separated from the rest of the drawer on the left side. In room #214, the toilet base was not secured to the floor, and both residents in the room confirmed they used the toilet. Staff D, a Certified Nursing Assistant, stated that a work order should be placed in the facility's electronic work order system if repairs are needed, but no such order was found for these issues. The Housekeeping Director stated that housekeeping cleans the bathrooms daily and would inform the Maintenance Director of any repairs needed, as housekeeping staff do not have access to the work order system. However, the Maintenance Director confirmed not having received any work orders for the issues in rooms #201 and #214. The facility was unable to provide a policy for Building/Equipment Maintenance when requested. Photographic evidence was obtained to support these findings.
Plan Of Correction
Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the accuracy of the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted to comply with the requirements set forth under state and federal laws and agencies. 1. The armoires drawer in was repaired on by the maintenance director. The toilet base in was secured to the floor on by the maintenance director. 2. Quality assurance check of all residents armoires and toilets was completed on by maintenance director. No additional findings were noted. 3. Facility staff received education on utilizing the TELS system for work orders by NHA or designee by . 4. Quality assurance checks on armoires and toilets will be completed by IDT members 3x a week for 6 weeks then 1x a week for an additional 6 weeks. All results of the quality assurance checks will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured.