Facility Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a safe and functional environment as required by regulations. During an offsite post-survey revisit, it was observed that a window in a resident's room was in disrepair, as it could not remain open without being propped up by a washcloth. Additionally, the window shade in the same room was found to have a black mold-like substance. Furthermore, a window in the corridor on the same floor was also in disrepair, being propped open with a glove box. These deficiencies were noted on one of the three resident floors. The Director of Maintenance acknowledged the issues, stating that the facility has central air conditioning for resident rooms and that the window shade would be replaced.
Plan Of Correction
Plan of Correction: Approved May 2, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element #1: The following actions were accomplished for the resident(s) identified in the deficient practice: - The window shade in room [ROOM NUMBER] was replaced on 3/24/25 by the maintenance department. - The window in room [ROOM NUMBER] and the corridor window were repaired by the maintenance director and maintenance assistant. Repairs included lubrication and replacement of pivot shoes and spiral tilt window balance. - A full house audit of windows and window shades was completed on 3/27/25 and any negative findings will be scheduled for repair. Element #2: The following actions will be implemented to identify other residents who have the potential to be impacted by the deficient practice: - All residents have the potential to be affected; however, no residents were negatively impacted. Element #3: The following system changes will be implemented to prevent reoccurrence: - Maintenance staff will be re-educated on the facility preventative maintenance requirements for windows. A record of education will be maintained for reference and validation. - All staff will be educated on maintaining and providing a safe and functional environment to residents; including reporting any observed repairs needed in the facility to the maintenance department via the facility work order system. A record of education will be maintained for reference and validation. Element #4: The facility’s compliance with the corrective action will be monitored using the following quality assurance system: - The Director of Maintenance has created an audit tool to ensure all facility windows are able to be opened and stay open without any outside intervention and that all window shades are present, clean, and in good repair. - The Director of Maintenance/designee will audit 25% of rooms 1 x week for 4 weeks then monthly thereafter for 3 months. Negative findings will be corrected immediately and reported to the administrator. - Results of audits will be reviewed during monthly QAPI meetings and the QAPI committee will determine ongoing audit frequency after three months of compliance. Element #5: The person responsible for the corrective action is the Director of Maintenance/designee. Date of Compliance is: 4/18/25.