Environmental Deficiencies Impacting Resident Safety and Comfort
Penalty
Summary
Multiple deficiencies were identified regarding the facility's failure to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Several residents reported malfunctioning overhead lights in their rooms, with one resident stating the light flickered and another indicating their light did not work at all. Staff confirmed these issues during observations. Additionally, a resident who received a replacement bed reported that the new bed's head would not go up or down, and another resident's overhead bed light required aggressive pulling to operate, which the resident was unable to do independently. Environmental concerns were also observed in common areas and food storage locations. The activities room had a ceiling tile with visible gray/black and brown discoloration, loose baseboards, and green and black bio growth near the sliding glass door and adjacent wall. Water was found collected in a garbage can under the affected area. In the east hallway pantry, the refrigerator and freezer were found to be operating at temperatures above safe ranges, with milk being lukewarm and frozen items thawed. The area under the pantry sink contained dark brown/black bio growth, and a ceiling tile above the door was partially hanging down. A wall fan had an opening to the outside environment, with leaves and debris present. Additional deficiencies included loose flooring in the east hallway and room 215, which could be lifted easily and posed a tripping hazard, as noted by a resident using a walker. In a three-resident room, one resident's air conditioning unit was not functioning, resulting in a room temperature of 80 degrees Fahrenheit, and the AC filter was covered in heavy black bio growth. The bathroom for these residents had a missing ceiling tile with exposed pipes. Facility staff and administration confirmed these findings during a tour and acknowledged the areas of concern.
Plan Of Correction
F921: 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 property. 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, e.g., 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.