Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment for its residents, as observed during a recertification survey. Several deficiencies were noted, including mismatched paint, uneven floors, and damaged furnishings in resident rooms. Specifically, a room in the West Wing had a ripped door kick plate, while another had mismatched paint and a stained, uneven floor. The main dining room also had an uneven floor with discolored tiles. In the East Wing, one room had unpainted walls and a bedside table in disrepair, while another had broken bedside tables and a mattress in poor condition. Additionally, dirt and grime were observed on the baseboard in the hallway and the porter's closet. The facility's policy on environmental services, which outlines guidelines for cleaning and disinfecting resident rooms, was not adhered to, as evidenced by the lack of documentation in the maintenance and housekeeping logbook for necessary repairs. The Director of Housekeeping and Maintenance acknowledged the issues, stating that terminal cleaning is performed daily, but repairs and replacements were pending due to ongoing building refresh efforts. The Administrator also noted the challenges of maintaining an older building but emphasized the importance of addressing these concerns to ensure a proper living environment for residents.
Plan Of Correction
Plan of Correction: Approved March 28, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element #1: West wing room [ROOM NUMBER] kickplate will be replaced. West wing room #18 will be painted and the floor repaired; tiles will be replaced. Main dining room floor and tiles will be repaired and made even. East wing room #4 will be painted and the bedside table will be replaced. East wing #10 bedside table and mattress will be replaced. The baseboards in the hallway and porters’ closet will be thoroughly cleaned. Element #2: The Director of housekeeping will inspect all other areas to ensure there is no mismatched paint or tiles and no other tables and mattresses are in disrepair. The Director of housekeeping will inspect the entire premises for cleanliness. Element #3: Maintenance staff will be in-serviced on ensuring furniture, mattresses, and rooms are not in disrepair. The housekeeping staff will be in-serviced on proper cleaning of baseboards and porter closets. The maintenance manual on preventative maintenance will be updated to include specifically mattresses, furniture, mismatched or broken tiles, painting, and uneven floors. The policy and procedure for general cleaning was reviewed with the housekeepers and no revisions were made. Element #4: An audit tool will be developed by the housekeeping director to audit rooms, common areas, and nursing stations to ensure cleanliness and preventative maintenance. Audits will be done weekly by the housekeeping director for three months and then quarterly. All findings and corrective actions, if indicated, will be discussed with the administrator. The Director of housekeeping will submit a status report to the administrator on a monthly basis. The Director of housekeeping will present findings and corrective actions, if indicated, to the QAPI committee, and thereafter the QAPI committee will determine the frequency of reports. Element #5: Administrator 5/01/2025