Deficiencies in Shower Room and Generator Enclosure Maintenance
Penalty
Summary
During a recertification survey, it was observed that a common shower room and the generator enclosure in the facility were not maintained in good repair. On multiple days, surveyors noted that one of the two common shower rooms on the 2West Nursing Unit was locked and inaccessible to residents due to a leaking issue from a compromised floor seal, which required the entire floor to be replaced. The Director of Maintenance confirmed the issue and stated that the shower room had been closed since an unspecified month in 2023. Additionally, the emergency generator enclosure was found to have signs of corrosion, with holes around rusted areas. The Life Safety Director acknowledged the generator's condition and indicated it would be addressed.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 I 310 – Physical Environment The following plan of correction is submitted in accordance with applicable law and regulation and for continued Medicare/Medicaid certification and does not constitute an admission of fault on the part of the facility. Immediate Corrective Action for Resident found to be affected by the deficient practice: Shower room – the quality of life of the residents on 2 west were not affected by the non-functioning shower room. The facility will correct this deficiency by repairing the compromised floor seal in the 2 west shower room. Repair to be completed on or before 02/18/2025. The functionality of the generator was not affected by rusted areas and corrosion of the generator enclosure. No residents were affected by the deficient practice. The generator enclosure will be repaired/replaced to ensure same is free of corrosion, holes and rusted areas on or before 02/18/2025. Identification of other Residents having the potential to be affected by the deficient practice: All residents have the potential to be affected by the deficient practice. Review of incident reports revealed no issues as a direct effect of the above-mentioned deficiency. All other shower rooms were inspected for functionality. There were no negative findings. There was no further generator enclosure to be inspected. Person responsible: Director of Maintenance Systemic Changes to ensure the deficient practice will not recur: Nursing Staff specifically Certified Nursing Assistants will be educated to notify the maintenance department if a shower room is in need of repair. The maintenance staff will be educated to inspect generator structure to ensure enclosure is free of corrosion, dust and holes. Education will be verified by posttests or return demonstration to ensure education retention. Person responsible: Nurse Educator QA – Monitor of the deficient practice: Audit tool will be created to inspect all shower rooms monthly x 3 months to ensure functionality. Any negative findings will be corrected. The Director of Maintenance/Designee will complete this audit and report results to QAPI quarterly. Audit tool will be created to inspect generator structures to ensure enclosure is free of rust, corrosion and holes. Any negative findings will be corrected. The Director of Maintenance/Designee will complete this audit and report results to QAPI quarterly. The Director of Maintenance is responsible for the correction of this deficiency. Date of correction: 02/18/2025