Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as observed during a recertification survey. In Unit 2, multiple issues were noted, including dirt and dust accumulation on medical equipment such as sphygmomanometer stands and oxygen concentrators, rust on mechanical lifts, and dusty nurse stations. The dining room had dusty fans, rust-stained suction machine tables, and missing or torn window shades. Additionally, wheelchairs were soiled, floor mats were torn and dirty, and clothes bins were embedded with debris. The facility had a signed construction contract for remodeling the second floor, but the work was pending material availability. In Unit 3, several deficiencies were observed, including peeling chairs in the nurses' station, missing floor linoleum, and radiators with crusty brown substances. Rooms had peeling paint, broken window shades, and dirty walls. The Maintenance Director acknowledged the lack of a painter and the need for additional maintenance staff. The facility's administrator confirmed the building's age and the need for extensive renovations, with plans to remodel the second floor but no proposals yet for Units 3 and 4. Unit 4 also exhibited significant issues, such as holes in the common bathroom walls, peeling paint, chipped tiles, and brown stains on ceiling tiles. A resident expressed a desire for their room to be repainted. The porter responsible for cleaning acknowledged the issues but was unsure if they had been reported to maintenance. The administrator noted the challenges in maintaining cleanliness due to resident behaviors and confirmed the need for further renovations across the facility.
Plan Of Correction
Plan of Correction: Approved April 1, 2025 I. Immediate Action a. Director of Environmental Services and Housekeeping Director did environmental rounds on 2nd, 3rd and 4th floor. b. All high touch surfaces, including nursing stations, closets, window sills, hand rails, fans, stands, lifts, suction machines checked and cleaned. Radiators, door frames cleaned and painted. c. Housekeeping Director checked all wheel chairs on the 2nd floor and scheduled cleaning. d. Director of Environmental Services made facility rounds noting which rooms need to be repainted. e. Director of Environmental Services made rounds of all window shades on 2nd and 3rd floor and replaced missing, torn, broken shades. f. Director of Environmental Services checked all chairs at nursing stations. All peeling and torn chairs, removed off unit, Administrator purchased new chairs. g. DON checked the condition of all binders. Old binders replaced with new ones. h. Director of Environmental Services repaired resident common bathroom including new tiles, paint and repaired holes. II. Identification a. Director of Environmental Services, Director of Housekeeping and Administrator made building wide facility rounds to identify areas of improvement. b. Facility respectfully states that all residents have the potential to be affected by this deficiency. III. Systemic Changes a. Administrator, Director of Housekeeping and Director of Environmental Services reviewed Safe and Homelike Environment Policy and found it to be compliant. b. Housekeeping Director in-serviced all housekeeping staff regarding the use of the Maintenance communication books at the nurses station when they see issues on the unit and in resident rooms. c. Director of Housekeeping and Director of Environmental Services to conduct weekly rounds on each unit. d. Full time maintenance employee hired. e. Full time housekeeper hired. Part time maid to be hired. IV. Monitoring a. Director of Environmental Services developed an audit tool for routine maintenance rounds to include window blinds, bathroom tiles, ceiling tiles, paint on radiators / ac units, walls, closets, windows, sinks. b. Administrator and Housekeeping Director developed an audit tool for cleanliness of units including nursing station, furniture, radiators, windows and more. c. Audit will be done weekly for 1 month, monthly for 3 months. d. All audit findings will be presented to the QA committee quarterly by the Director of Environmental Services and Housekeeping Director / designee. V. Responsibility: a. Director of Environmental Services and the Housekeeping Director will be responsible to ensure correction of this deficiency.