Failure to Maintain Clean and Safe Physical Environment
Penalty
Summary
The facility failed to effectively clean and maintain the physical plant, impacting 61 residents. During environmental tours of both common areas and resident rooms, surveyors observed multiple deficiencies, including loose grab bars, damaged and soiled chair cushions, missing atmospheric vacuum breakers on shower wands, and soiled janitor closets and ventilation grills. Overhead light assemblies were found to be non-functional or soiled with dust, dirt, and dead insects. Several areas, such as the dining room and storage rooms, had missing or damaged flooring and light covers, and hand sinks were noted to be draining slowly. In resident rooms, numerous issues were identified, such as cracked or broken light covers, non-functional lights, missing pull string extensions, loose or missing commode seats and caulking, and heavily soiled ventilation grills. Human fecal material was observed on drywall surfaces and adjacent to restroom shower stalls in some rooms. Additional problems included ill-mounted doors, missing thermostat covers, and loose enable bars, all of which contributed to an environment that was not adequately maintained or cleaned. Record reviews revealed that the facility had policies and procedures in place for maintenance inspections, preventative maintenance, and routine cleaning and disinfection. However, the review of work orders for the previous 60 days showed no documentation of the identified maintenance concerns, indicating a lack of follow-through on the facility's stated policies. These findings collectively demonstrate a failure to ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public.
Plan Of Correction
F921 – Safe/Functional/Sanitary/Comfortable Environment Element #1: Environmental deficiencies listed below will be addressed: - The wall-mounted grab bars in therapy near the scale were repaired. - Damaged chairs in therapy were replaced. - Shower wand assemblies were equipped with an atmospheric vacuum breaker. - The floor and mop sink basin in the janitor's closet were cleaned. - Return air exhaust ventilation grills were cleaned in the nurse station restroom, the soiled utility room, the activities storage room, Rm 124 restroom, Rm 130 restroom, Rm 131 restroom. - Overhead light assemblies were repaired and/or cleaned in the lift storage room, the main dining room, Rm 102 bed 2, Rm 117 bed 1, Rm 122 bed 1, Rm 123 bed 1, Rm 128 bed 1, Rm 129 bed 2, Rm 135 bed, Rm 135 restroom, and Rm 143 entrance light. - Beauty shop hand sink basins were repaired to ensure proper drainage. - Flooring was repaired in the storage room. - Commode base caulking was repaired in Rm 101, Rm 102, Rm 111, Rm 122, Rm 124, Rm 128, Rm 130, Rm 131, Rm 135, and Rm 143. - Rm 101: drywall was cleaned above the waste receptacle. - Rm 117: Restroom door was repaired to ensure proper mounting and close to a positive latch. - Rm 122: The wall-mounted thermostat, and restroom faucet assembly were repaired. - Rm 123: The commode seat and cove base were repaired. - Rm 127: Bed 2 metal frame was assessed and repaired. - Rm 128: The commode seat was repaired. - Rm 133: The commode support and seat were repaired. Restroom interior door was repaired. - Rm 135: Bed 2 enabler bar and restroom toilet paper holder were repaired. The restroom was cleaned. Element #2: The Maintenance Director initiated a full facility walkthrough to identify and resolve any additional safety, sanitation, or functional issues. Element #3: The Administrator reviewed the policy on Resident Environmental Quality, and Routine Cleaning and Disinfection, and revised as necessary. Community staff were re-educated on the policies. Element #4: The Maintenance Director and/or designee will conduct weekly environmental rounds for 12 weeks to ensure compliance with the regulation. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025