Unsecured Freestanding Closets in Resident Rooms
Summary
During a Life Safety Recertification Survey, it was observed that the facility did not maintain a functional and comfortable environment for residents due to unsecured freestanding closets in certain resident rooms. These closets were not attached to the walls, posing a risk of tipping over. The Director of Maintenance explained that some closets had recently arrived and others had been moved for cleaning, and staff were still in the process of securing them. This situation was identified during observations and staff interviews conducted on the survey dates.
Plan Of Correction
Plan of Correction: Approved April 26, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Action 1) On 4/21/25, freestanding closets in resident rooms [ROOM NUMBERS] were secured to the wall to reduce the risk of tipping over. II. Identification of Other Residents: 1) The facility has reviewed all other closets to ensure that they were securely fastened. No other resident was noted to be involved. III. Systemic Changes: 1) The facility reviewed the policy on replacement of room furnishings and found no required changes. 2) All engineering and EVS staff responsible for replacing furniture were inserviced on the policy. 3) Before furniture is replaced staff will be reviewed on the policy. IV. Q/A Monitoring 1) The Director of Environmental Services will conduct 10 randomly selected resident rooms per month for QAPI audits over the next quarter to determine if compliance is ongoing and report to administration for future facility improvement. 2) Audits of negative findings will have immediate corrective actions implemented. 3) Audit findings will be presented monthly to the Administrator and to the QA Committee quarterly for evaluation and follow-up. V. Responsible Person: Director of Maintenance/Director of Environmental Services
Penalty
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