Environmental Deficiencies in Spa and Linen Areas
Penalty
Summary
During a facility tour with the Maintenance Director, surveyors observed several environmental deficiencies. In the spa room near the activities area, there was a strong odor and a bowel movement left in the commode, with clean folded towels stacked next to the sink. The shower floor in the same room had approximately a dozen one-inch square tiles missing near the front, and a piece of trash identified as a gold tooth filling was found on the floor. The Maintenance Director was unaware of these issues and could not identify if any resident was missing a tooth filling. In the clean linen room, the bottom rack of the linen cart was open wire shelving, leaving clean linens exposed to contamination, and there was an accumulation of trash, dust, and dirt under the cart, which was rarely moved. In another spa room at the end of the hall, a bowel movement was found in the commode and smeared on the padded cover for the plumbing under the sink, and dust was observed on unused equipment and the shower fixture.
Plan Of Correction
ELEMENT 1 ACTION TAKEN: The spa room near the activities center was deep cleaned and the area of the floor where there were missing tiles will be repaired by 5/26/2025. The floor in the clean linen room was cleaned. A solid surface shelf was installed on the bottom shelf of the clean linen cart in the clean linen room. The spa room at the end of the hall was deep cleaned including the padding of the plumbing pipe under the sink that was also sanitized. ELEMENT 2 IDENTIFICATION OF OTHER RESIDENTS: The facility will conduct a resident council meeting by 5/26/2025 where residents will have the opportunity to express any concerns related to their living environment. Any identified concerns will be addressed through the resident grievance process. ELEMENT 3 MEASURES TAKEN: All staff will receive reeducation by or prior to 5/26/2025 or the next day worked in the case of a leave of absence or vacationing employee related to the standards of providing a safe, functional, sanitary, and comfortable environment to ensure satisfaction of the living environment is maintained for residents, staff, and visitors. ELEMENT 4 MONITORING: The Nursing Home Administrator and or designee will conduct an audit through observation during rounds in the facility 3-5 times a week for four weeks, and periodically thereafter. The observations will be of various areas and rooms throughout the facility to ensure a safe, functional, sanitary, and comfortable living environment is maintained. Examples of locations to audit are shower rooms, resident rooms, storage rooms, linen closets, dining rooms, etc. A summary report of the findings will be provided to the QAPI Program/Committee for review. The Administrator will assume responsibility for attained and sustained compliance.