Failure to Maintain Safe, Clean, and Homelike Environment for Residents
Penalty
Summary
Three deficiencies were identified regarding the facility's failure to provide a safe, clean, and homelike environment for three residents. One resident's personal wheelchair went missing two to three weeks prior and was not reported to the Social Services Director as required. The resident, who had moderate cognitive impairment and relied on the wheelchair for mobility, reported the loss to a CNA, but no theft and loss report was initiated. The absence of the wheelchair limited the resident's ability to move freely and participate in activities such as going outside to smoke. Another resident, who had severe cognitive impairment and required assistance for toileting, was found to have a broken toilet seat in their bathroom. The seat was loose and missing a screw, leaving it detached from the toilet rim. The issue was reported by the resident's responsible party to staff, but the seat remained unrepaired at the time of observation. The resident's care plan indicated a risk for injury due to falls, and the broken seat presented a potential hazard during transfers. A third resident, who was dependent for all activities of daily living and had severe cognitive impairment, was found in a room where the patio sliding door could not be fully closed. Cold air was entering the room, and the maintenance supervisor was unable to close the door due to dirt in the track. The door had no screen, and it was noted that it was going to rain that day. The DON confirmed that such conditions were not homelike and could lead to discomfort or illness for the resident. Facility policies required prompt investigation of missing property, maintenance of equipment in good repair, and provision of a homelike environment, but these were not followed in the cited instances.
Plan Of Correction
F 584: Safe/Clean/Comfortable/Homelike Environment CORRECTIVE ACTION Resident 11's personal wheelchair was reported missing to the Social Services Director (SSD), and on 3/7/2025, a replacement wheelchair was provided for Resident 11. On 3/7/2025, Maintenance Director secured and fully attached the toilet seat in Resident 63's bathroom. On 3/10/2025, Maintenance Director repaired Resident 68's patio door to ensure it could be fully closed. OTHER RESIDENT AFFECTED IDENTIFICATION On 3/7/2025, the administrator and maintenance supervisor conducted environmental rounds to ensure all residents had a clean and safe environment. They confirmed that all patio doors could be fully closed and toilet seats were securely attached. No other residents were found to be impacted by the alleged deficiencies. On 3/7/2025, the SSD performed an inventory of residents with personal wheelchairs. No other residents were found to be affected by the alleged deficiency. MEASURES AND SYSTEMIC CHANGES Department heads will perform daily room rounds from Monday to Friday, ensuring that equipment in residents' rooms is in good working condition. Findings will be communicated to the leadership team during the daily standup. Maintenance staff will conduct monthly room rounds for all residents' rooms to verify that doors and toilet seats are in proper working condition. Upon a resident's new admission or issuance of a personal wheelchair, licensed staff must inventory the wheelchair and ensure it is marked for the resident's use only. Any missing or lost personal wheelchairs must be documented in the theft and loss log by the SSD/SSA for resolution. MONITORING PERFORMANCE The Maintenance Supervisor will present the findings from maintenance logs, specifically regarding the environmental inspections of patio doors and toilet seats, to the monthly Safety Committee for three months or until compliance is achieved for further review and recommendations. The Administrator is responsible for ensuring the continuity and sustainability of this process. The SSD will report any instances of lost or missing personal wheelchairs to the monthly QAA Committee for monitoring. 3/28/2025