Deficiencies in Physical Environment and Equipment Maintenance
Penalty
Summary
Multiple deficiencies were identified in the facility's physical environment, impacting both resident rooms and common areas. Observations revealed that several residents had non-functional or malfunctioning overhead lights, with some lights flickering or not working at all. In one case, a resident received a replacement bed that was also not fully operational, as the head of the bed would not adjust. Additionally, air conditioning issues were noted, with one resident's AC unit not providing airflow and the filter covered in heavy black bio growth, resulting in a room temperature of 80 degrees Fahrenheit. Another room had a missing bathroom ceiling tile with exposed pipes. Common areas, including the activities room and pantry, exhibited significant maintenance and sanitation concerns. The activities room had a ceiling tile with visible water damage and bio growth, loose baseboards, and bio growth outside the sliding glass door. The pantry refrigerator and freezer were found to be operating at temperatures above safe ranges, with perishable items such as milk and ice cream thawed and not properly chilled. The pantry also had a large collection of dark bio growth under the sink, a partially hanging ceiling tile, and an exterior wall vent with an opening to the outside environment. Throughout the facility, loose flooring was observed in hallways and resident rooms, with some areas easily lifted by foot and posing a tripping hazard. Residents and staff confirmed these issues during interviews and walkthroughs. Facility leadership, including the NHA and DON, were made aware of these deficiencies during the survey and acknowledged the findings.
Plan Of Correction
What corrective actions (s) will be accomplished for those residents found to have been affected by the deficient practice: 1. By 7/12/2025, Residents #5, #6, #7, #11, #12, and #13 interviews and room audits completed. 2. By 7/12/2025, Residents #5, #6, and #11 overbed light repaired. 3. By 7/12/2025, Resident #7 bed replaced with head of bed working properly. 4. By 7/12/2025, the ceiling tile in the activities room on the south hallway replaced. 5. By 7/12/2025, the loose baseboard along the perimeter of the activities room was replaced. 6. By 7/12/2025, the bio-growth substance outside of the sliding glass door to the left of the activities room exiting to the courtyard was cleaned. 7. By 7/12/2025, the ceiling outside of the activities room adjacent to the ceiling tile was repaired and repainted. 8. By 7/12/2025, the refrigerator in the nourishment room on the east hallway was removed, discarded and replaced. The cupboard under the sink of the east pantry was cleaned. The ceiling tile above the door was replaced. The exhaust fan in the wall was cleaned. 9. By 7/12/2025, the air conditioning was replaced in Resident #12 and #13 shared room. The missing ceiling tile in the bathroom was replaced. The flooring in Resident #12 room was replaced. 10. By 7/12/2025, the loose flooring was replaced/repaired in the east 200 hallway. How will you identify other residents having potential to be affected by the same practice and what corrective actions will be taken: By 7/12/2025, resident interviews, resident room and common area audits will be conducted to ensure equipment is safe, sanitary, comfortable, and operational. The audit will include resident room HVAC, refrigerator and cupboards in pantry rooms, ceiling tiles, flooring, beds for proper function, resident room overbed lights, and fans in the pantry rooms. Maintenance equipment and/or environmental items identified on the audit will be repaired and/or replaced as appropriate. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: 1. By 7/12/2025, the Administrator and/or designee will educate staff on reporting safe, sanitary, comfortable, and operational equipment via TELS. 2. Newly hired staff will be educated on reporting safe equipment, maintenance, and environmental concerns via TELS. How the corrective actions will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The administrator and/or designee will conduct an interview of 5 residents and audit 5 resident rooms on each unit to ensure equipment is safe, sanitary, comfortable, and operational weekly for 4 weeks then monthly for 3 months. The findings of the audits will be reported to the QAPI committee monthly until the committee determines substantial compliance has been met and sustained.