Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by several deficiencies observed during a recertification survey. In room C-19-B, a broken window latch was noted, with a hand-written sign instructing not to open the window, indicating a lack of awareness and action from the maintenance staff. Room C-9-B had a broken radiator cover, stained window shades, and black scuff marks on the wall, with the Director of Maintenance unaware of these issues due to the absence of work order requests. Additionally, room A-17 had a faulty window unit and a Packaged Terminal Air Conditioner unit that allowed cold air to enter, with the Director of Maintenance acknowledging the problem but citing pending warranty discussions and weather conditions as reasons for the delay in repairs. The Director of Maintenance admitted to not being informed about the environmental concerns in rooms C-19-B and C-9-B, as no work orders were submitted. The facility's policy requires staff to report such issues to their unit manager, who should then enter a work order into the maintenance software. Despite a complaint from a resident in room A-17 about cold air entering through the air conditioner unit, the facility had not yet resolved the issue, pending warranty discussions and warmer weather for repairs. These deficiencies highlight a breakdown in communication and maintenance processes, leading to an environment that does not meet the required standards for resident comfort and safety.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 I. Immediate Corrective Action: 1. Room C-19-B: - On 3/6/25, Maintenance staff inspected the window in Room C-19-B. The broken window latch was repaired, and the Do not open sign was removed. 2. Room C-9-B: - On 3/6/25, Maintenance repaired the broken radiator cover and secured it properly. - On 3/6/25, Housekeeping cleaned the stained window shade and replaced it. - On 3/6/25, Maintenance cleaned the black scuff marks on the wall between the dresser and window/radiator area. 3. Room A-17: - On 3/11/25, Maintenance identified the faulty PTAC. Temporary sealing was applied to prevent outside air from entering. Maintenance placed a temporary seal on the Packaged Terminal Air Conditioner (PTAC) unit to minimize the cold air entering the room. - The facility will complete permanent repair of the window and PTAC unit as soon as the weather permits, with a target completion date of 4/30/25. II. Identification of Others: - All residents in the facility could potentially be affected by similar environmental issues. - The Director of Maintenance conducted a thorough environmental round in all resident rooms to identify any additional issues like those found in Rooms C-19-B, C-9-B, and A-17. All identified concerns will be fixed. III. Systemic Changes: 1. The Director of Maintenance reviewed the Maintenance/Engineering policy and incorporated a procedure for Sequra (Maintenance Tracking Software) emphasizing staff responsibility for reporting environmental concerns via the work order system. Maintenance staff now follow up daily to ensure timely resolution. 2. All Management staff were educated on the updated policy and how to effectively use Sequra to track maintenance requests. IV. Quality Assurance: - An audit tool was created by the Director of Maintenance to track environmental concerns. - Weekly audits of all rooms will be conducted for 4 weeks by the Maintenance Director and findings will be discussed at daily meetings. A monthly audit will continue for 11 months. - The results of audits and any corrective actions will be reported to QA. V. Person Responsible: - Director of Maintenance