Facility Fails to Maintain Clean and Comfortable Environment
Penalty
Summary
The facility failed to provide a clean and comfortable environment for three residents, as evidenced by observations and interviews. Resident #2 reported seeing roaches frequently in her room, despite pest control efforts, and noted heavy dirt residue on the floors. Staff A confirmed the pest control company was ineffective. Resident #3's representative expressed dissatisfaction with the room's cleanliness, pointing out dried splashes on walls, doors, and curtains, along with dirt accumulation. Resident #4's room had heavy ceiling damage and dirt debris, with the Director of Maintenance acknowledging the need for repairs and cleaning. The Director of Maintenance and Housekeeping services admitted that their cleaning machines had been broken for over a month, leading to ineffective cleaning methods. During an environmental tour, the Director agreed that Resident #3's room required cleaning and repainting, and Resident #4's room needed attention. The Administrator was informed of the cleanliness and pest concerns, acknowledging the issues raised by residents and their families.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. Safe/Clean/Comfortable/Homelike Environment A) What corrective action will be accomplished for those residents found to have been affected by this practice? a. On Resident #2s room was treated for roaches. On heavy dirt residue was removed from the edges and corners of floors in the room and bathroom. b. On Resident #3s room was repainted, deep cleaned, curtains replaced, walls were wiped down and bathroom door was cleaned. Dirt accumulation along edges and corner of floors removed. c. On Resident #4s ceiling was repaired. Resident #4s curtain was replaced. Heavy dirt debris on the floor corner and edges were cleaned. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. By, audit completed in all resident rooms to ensure concerns with pest control were addressed. b. By, deep cleaning schedule audit completed to address residents rooms and bathrooms, floors, floor edges/corners, walls in need of repainting, or repairs. Repairs to be completed as indicated on deep cleaning calendar. c. By audit completed to ensure cubical curtains do not have stains or dry splashed feed in residents rooms. d. On, audit completed to identify ceiling damage, holes, and/or curtain tracks in need of repair. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. By, the ED/designee educated the environmental services supervisor and maintenance director on ensuring that resident rooms are treated appropriately for roaches. Rooms and bathroom walls, floors-edges/corners of floors, and curtains are repaired/maintained in good, clean condition. b. By the ED/designee educated staff on identifying, and timely reporting environmental concerns in TELS. D) How will the corrective actions be monitored to ensure the practice will not reoccur; what quality measures will be put into place? a. ED/designee to randomly audit resident rooms to ensure that there are no concerns with pest control. b. ED/designee to randomly audit 6 resident rooms and bathrooms to ensure that they are clean and in good repair, paint touch-ups are made timely, curtains are devoid of holes/stains, and floors and corners are clean. c. ED/designee to randomly audit ceiling damage and holes around curtain tracks to ensure ceiling is in good condition. d. Audits will be conducted weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. Findings will be reported monthly at the QA/Risk management meeting until such time substantial compliance has been determined.