Failure to Maintain Safe, Clean, and Homelike Environment for Multiple Residents
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for seven residents, as evidenced by multiple observations and interviews. One resident's closet handle was found to be replaced with a plastic trash bag loop, which the resident used to make it easier to open the door. The Director of Staff Development acknowledged that this posed a safety risk, as residents could get caught in the loop and injure themselves. Another resident's bed sheet was observed to be worn out, thin, discolored, and old, with confirmation from a Licensed Vocational Nurse that the sheet needed replacement. In a shared restroom used by two residents, towels were found hanging on various fixtures such as the soap dispenser, toilet paper holder, and shower hose, rather than on a proper towel rack. The ceiling paint in the restroom was also peeling. One resident expressed concern about the lack of a towel rack and the unsanitary conditions, while the other resident noted the safety risk of reaching for towels in unsafe locations. The Director of Staff Development agreed that the situation was unsafe, unsanitary, and not homelike. Another resident's room wall near the head of the bed was observed to have discolorations and multiple scratches, which the resident found unpleasant. The Maintenance Director stated that the damage was likely caused by the bed hitting the wall and agreed that it did not create a homelike environment. Additional deficiencies included a rollator walker with a chipped seat cushion exposing foam for one resident, and a wheelchair in poor condition for another resident, with a cracked armrest held together by tape, a sagging and cracked backrest, and missing vinyl. The affected resident reported discomfort and had previously requested a new wheelchair. The Maintenance Supervisor and DON confirmed the importance of maintaining assistive devices in good repair and acknowledged the poor condition of the wheelchair. Facility policies reviewed indicated requirements for maintaining a clean, safe, and homelike environment, as well as regular maintenance of equipment, which were not met in these instances.
Plan Of Correction
b. The Housekeeping Supervisor replaced the worn-out bedsheet of resident 55 on 6/9/25. c. The Maintenance Supervisor installed a towel rack on 6/17/25 in the shared restroom for Residents 37 and 57. On 6/17/25, the Maintenance Supervisor patched the ceiling of the restroom for Residents 37 and 57. d. On 6/18/25, the Maintenance Supervisor painted the wall for resident 64, near to the head of the resident bed. e. The Maintenance Supervisor replaced on 6/9/25 Resident 7's rollator with a newer one. f. The Maintenance Supervisor replaced on 6/9/25 Resident 66's wheelchair with a newer one. Corrective Action for Others Affected a. On 6/16/25, the Maintenance Supervisor began daily rounds and found no other residents affected by the deficient practice related to paint and wheelchairs and rollators. Measures Taken to Prevent Reoccurrence a. The Administrator in-serviced the Housekeeping Director on 6/16/2025 regarding quality control in the distribution of linens. b. The DSD in-serviced the CNA staff on 6/16/2025 regarding safe, clean, comfortable home-like environment. c. The Administrator in-serviced the Maintenance Supervisor on 6/17/25 regarding proper maintenance of wheelchairs, walkers, and rollators. Performance Monitoring to Ensure that Solutions are Sustained a. Beginning 6/16/25, the DSD shall make random rounds monthly, for the next 3 months, and check 5 random rooms to make sure that residents are using good quality linens. b. Beginning 7/01/25, the Maintenance Supervisor will report monthly to the Administrator on the status of painting and patching for the next 3 months.