Facility Deficiencies in Environmental Maintenance
Penalty
Summary
The facility was found to have deficiencies in maintaining a comfortable and sanitary environment for residents, as required by regulations. Observations revealed that in two of the four nurse units, there were issues such as peeling paint on corridor walls and around door frames, non-functional exhaust fans in a nurse station's toilet and a resident's room, and unsecured handrails by a ramp. Additionally, a resident's room on the first floor had peeling paint around the window frame and stained ceiling tiles. These deficiencies were noted during a survey conducted over two days, with the Director of Maintenance and the Administrator present during the observations. The Director of Maintenance stated that housekeeping staff clean residents' rooms, toilets, and floors daily, but these activities are not recorded. The Director also mentioned that daily walkthroughs are conducted to identify issues needing repair, such as peeling paint, and that environmental staff receive training every three months. Despite these measures, the facility acknowledged the findings and indicated plans to repaint and renovate the affected areas, although no definitive timeline was provided for these actions.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Pine(NAME) Center For Rehabilitation and Healthcare provides the following Plan Of Correction. 1. No residents were affected by this deficient practice. 2. All Residents have the potential to be affected by this deficient practice. 3. The toilet in room [ROOM NUMBER] has been repaired by the maintenance team. 4. The maintenance team has started plastering/repainting/repairing the entire second floor. 5. The handrail by the ramp has been readjusted and tightened to ensure it is firmly secured. 6. Room [ROOM NUMBER] has been plastered and repainted, and stained ceiling tiles have been replaced. 7. An exhaust fan for the second floor bathroom was purchased and installed by the maintenance team. 8. The EVS Director inserviced all his staff on the facility's policy on high dusting. 9. Audits will be conducted every week for the first 4 weeks and monthly for the next 3 months to ensure high dusting is completed. 10. The EVS Director/designee will ensure any items put into the facility's maintenance system are immediately addressed. 11. The EVS Director will report any findings at the quarterly QA/QAPI Meetings. 12. The EVS Director will be responsible for the correction of this deficiency.