Failure to Maintain Safe, Sanitary, and Comfortable Environment
Penalty
Summary
Multiple deficiencies were identified regarding the facility's failure to provide a safe, clean, comfortable, and homelike environment for residents. Several residents reported malfunctioning overhead lights, with one resident stating their light flickered on and off and another's did not work at all. Staff confirmed these issues but did not immediately resolve them. Another resident received a replacement bed due to a malfunction, but the new bed's head mechanism was also nonfunctional, requiring the resident to restart the request process. In another case, a resident's overhead bed light required aggressive pulling to operate, which the resident was unable to do independently. Environmental observations revealed significant maintenance and sanitation issues in both resident and common areas. The activities room had a ceiling tile with visible mold-like growth, loose baseboards, and water accumulation in a garbage can. The area outside the activities room showed bio growth and peeling paint, with missing ceiling texture and further mold-like substances. The pantry room's refrigerator and freezer were operating at unsafe temperatures, resulting in thawed and lukewarm food items. 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 debris and an opening to the outside. Flooring in multiple areas was loose and could be lifted easily, posing a tripping hazard, as noted by a resident using a walker. Additional deficiencies included a resident room with a non-functioning air conditioning unit, resulting in a noticeably warmer environment and a hygrometer reading of 80°F. The AC filter was covered in black bio growth, and a missing bathroom ceiling tile exposed pipes. These issues were confirmed by facility leadership during a walkthrough. The facility's own policy requires maintaining a clean, safe, and orderly environment, but observations and interviews demonstrated that these standards were not met in several areas, affecting both resident rooms and shared spaces.
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.