Failure to Maintain Safe and Homelike Resident Room Conditions
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as required by federal regulations. During an inspection of resident rooms, it was found that three residents' rooms had significant issues with ceiling tiles. Specifically, one room had a damaged, brown and black discolored ceiling tile above the bed, another room had three damaged and discolored ceiling tiles, one broken ceiling tile with a portion missing, and one entire ceiling tile missing, while a third room had three damaged, brown and black discolored ceiling tiles above the bed. These deficiencies were confirmed during an interview with the Maintenance Director, who acknowledged the conditions of the rooms. The observations directly indicate that the facility did not provide the necessary housekeeping and maintenance services to ensure a sanitary, orderly, and comfortable interior, as well as failing to maintain the physical environment in a manner that supports resident safety and comfort.
Plan Of Correction
Tag Number: F584 Deficiency: The facility failed to provide a homelike environment by having ceiling tiles that had brown stains on them. Residents #54, #81, and #116 were affected by this deficient practice, with no negative outcomes. Ceiling tiles for the affected residents were changed by maintenance staff on 6/6/2025. A facility-wide audit was conducted to identify any ceiling tiles with stains on them on 6/21/25 through 6/23/25 and replaced by the Maintenance staff. The ED/designee provided education to the Maintenance supervisor and staff on ceiling tiles and cluttered rooms on 6/9/25. Weekly rounds by the Maintenance supervisor/designee to ensure that ceiling tiles are in good condition will be conducted for 4 weeks, and then twice monthly for 2 months. Results will be reviewed by the QAPI Committee and used to guide continuous improvement. Date of Compliance: July 10th F 0584