Failure to Maintain Cleanliness and Physical Plant Integrity
Penalty
Summary
The facility failed to effectively clean and maintain the physical plant, impacting 60 residents. During an environmental tour, multiple areas were observed with soiled and encrusted dust/dirt deposits on return-air-exhaust ventilation grills, including shower rooms, staff and public restrooms, and resident rooms. Additionally, several chairs in common areas and resident rooms were found to be damaged, with surfaces etched, scored, and exposing inner Styrofoam padding. In the kitchen storage room, a broken atmospheric vacuum breaker was noted on the mop sink faucet assembly, and several shower wand assemblies in resident rooms were missing atmospheric vacuum breakers. Interviews with the Maintenance Director revealed that the facility uses the TELS system for maintenance work orders. However, a review of the TELS work orders for the past 60 days showed no specific entries related to the observed maintenance concerns. The facility's policies for maintenance and housekeeping require ongoing monitoring and thorough cleaning of environmental surfaces, but these procedures were not followed as evidenced by the observed deficiencies. The lack of effective cleaning and maintenance increased the likelihood of cross-contamination, bacterial harborage, reduced air quality, and potential cross-connections between potable and non-potable water supplies. The findings were based on direct observations, interviews, and record reviews, with no documentation indicating that the identified issues had been previously addressed through the facility's maintenance system.