Facility Fails to Maintain Clean and Functional Environment
Penalty
Summary
The facility failed to effectively clean and maintain its physical plant, affecting 91 residents. During an environmental tour of the facility's laundry service, it was observed that the clean laundry room had a leaking hand wash sink cold water supply valve and soiled overhead light assembly lens covers. In the soiled laundry room, transport carts were found to be etched and scored, creating non-cleanable surfaces. Additionally, the common areas, including the nurses' station and staff restrooms, were noted to have accumulated dust and dirt deposits, and several light assemblies were non-functional. In various units, multiple deficiencies were observed, including stained ceiling tiles, loose commode supports, and non-functional resident call systems. The nursing supply closets had bare and unsealed shelving units, and the emergency water supply closet was in disarray with soiled containers. Resident rooms across different units had non-functional light assemblies, missing pull string extensions, and damaged drywall surfaces. The commode base caulking in many restrooms was etched and scored, and several hand sink basins were draining slowly. The facility's policies and procedures for cleaning schedules and preventative maintenance were reviewed, revealing that routine cleaning and maintenance were not performed according to the predetermined schedule. The Direct Supply TELS work orders for the last 60 days showed no specific entries related to the maintenance concerns identified during the survey. This lack of adherence to cleaning and maintenance protocols increased the likelihood of cross-contamination and bacterial harborage, posing a risk to the safety and comfort of residents, staff, and the public.
Plan Of Correction
Element #1 Clean Laundry Room: Hand wash sink leak was fixed. Overhead light assembly clear plastic protective lens covers cleaned. Soiled Laundry: 6 new laundry transport carts were ordered. Nurses station: 6 new chairs were ordered. Staff Restroom: return-air-exhaust cleaned Shower Room (A): wand assembly corrected light assemblies functioning, hand sink basin re-secured. Call light system corrected. Nursing Supply Closets ALL now have painted, sealed shelves. Stained ceiling tiles replaced. Womens Locker Room: sink drain repaired, cove base reinstalled, Emergency Water Supply area cleaned with new shelving purchased. Staff Breakroom was cleaned including the toaster and refrigerator freezer unit. A11 - The restroom overhead light assembly was fixed. The restroom commode base perimeter was also cleaned and caulked. B1 - The restroom over sink light assembly was fixed. The restroom commode base perimeter caulking was redone. The interior and exterior commode base surfaces were cleaned. The window ledge drywall surface was repaired. The floor mounted heating grill assembly was replaced. B7 - The commode base caulking was redone. B9 - The floor mounted heating grill plate was replaced. C2 - Commode base caulking was repaired. The restroom sink was unclogged and is draining normally. C3 - The Bed 1 over bed light assembly pull string was replaced. The Bed 2 floor mounted anti-skid strips were replaced. The restroom over sink light assembly corrected and is functioning. The restroom commode base caulking was replaced. The restroom bathtub interior surface and perimeter surround was cleaned. The Bed 1 over bed light assembly pull string was added. C6 - The Bed 2 over bed light assembly pull string extension was replaced. The restroom overhead light assembly was also fixed. The restroom commode base caulking was redone. The restroom commode base seat was replaced. C-7 - The restroom commode base caulking was repaired. The restroom over sink light assembly was also corrected. The restroom overhead light assembly protective lens cover was cleaned and replaced. The Bed 2 drywall surface was further observed (etched, scored, particulate), adjacent to the footboard. The damaged drywall surface measured approximately 4-feet-wide by 4-feet-long. C9 - The restroom commode base caulking was redone. The restroom overhead light assembly was also corrected. C-10 - The restroom commode base caulking redone. The restroom hand sink basin was unclogged and is draining normally. The restroom perimeter wall/flooring coving strip was reinstalled and is no longer loose. D2 - The restroom commode base caulking was redone. The restroom over sink light assembly was also corrected. The restroom commode support was additionally tightened. D-3 - The restroom commode base caulking was replaced. The restroom overhead light assembly was also corrected. The Bed 2 drywall surface was repaired. D7 - The commode base caulking was replaced. The restroom and sink basin caulking was also replaced. The drywall surface was repaired. D-9 - The restroom commode base caulking was replaced. The restroom commode base was also tightened. The restroom commode support was additionally tightened. The restroom over sink light assembly was repaired. The restroom overhead light assembly lens cover was also cleaned. The Bed 1 over bed light assembly pull string extension was replaced. D-11 - The restroom commode base caulking was repaired. The restroom commode base was also tightened. The restroom commode support was additionally tightened. The restroom over sink light assembly was fixed. The restroom overhead light assembly lens cover cleaned. The Bed 1 over bed light assembly pull string extension was added. D-13 - The Bed 1 over bed light assembly pull string extension was added. The restroom commode base caulking was also replaced. D-17 - The restroom commode base caulking was redone. The restroom overhead light assembly lens cover was cleaned. Element 2 Residents who reside in facility are considered at risk. Facility-wide audit was completed to ensure a safe and sanitary environment is possible for all residents. Findings were entered into TELS and corrected by facility maintenance. Element 3 The Administrator has reviewed the Preventative maintenance policy and cleaning schedules policy and deemed them appropriate. Staff have been educated on the use of the TELS work order system. Staff will utilize TELS daily to submit needed work orders. Element 4 NHA or designee will audit 10 areas each week x4 weeks, then monthly to ensure proper maintenance needs have been met, and surfaces are cleanable. Results will be reviewed monthly by QAPI until substantial compliance achieved. Administrator is responsible for overall compliance.