Failure to Maintain Safe and Homelike Environment Due to Rusted Bathroom Equipment
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment as required by state regulations. Specifically, during facility tours, it was noted that three resident rooms (112, 113, and 116) had over-the-toilet seats that showed visible signs of rust. These observations were made on two separate occasions, confirming the ongoing presence of the issue. The deficiency was documented through direct observation and photographic evidence. Interviews with the Director of Maintenance revealed that maintenance work orders are managed on paper, with staff responsible for reporting issues daily. Although the facility has a maintenance inspection sheet intended for preventative room checks, the Director of Maintenance admitted that these room checks were not currently being performed. Review of facility policies and inspection forms indicated that procedures for routine cleaning, disinfection, and room inspections exist, but the relevant documents were either unsigned, undated, or not being actively implemented.
Plan Of Correction
Specific Corrective Action A full inspection of all resident rooms was conducted on 7/18/2025, identifying all over-the-toilet toilet seats that had any rust or damage. Twelve new 3-in-1 over-toilet folding commodes were ordered on 7/18/2025 (Attachment A). Three seats arrived the same day and were placed in identified rooms. The remainder of the new equipment arrived on 7/25/2025, with three seats going to replace existing equipment and the remainder going to storage for future utilization. Method to Assess Other Residents A comprehensive survey of all resident rooms was conducted on 7/18/2025 to identify any other equipment of concern (Attachment 8). All residents of this facility have the potential to be affected by this practice. Systematic Review The "Resident Room Inspection" form was updated (Attachment C) to include the 3-in-1 toilet seats. Health Center Maintenance staff were educated on the SNF Room inspection policy and the new resident room inspection sheet on 7/28/2025 (Attachment D). Quality Assurance The Plant Manager or designee will complete random weekly audits for 3 months during the weeks of 7/28/25 through 9/29/2025 (Attachment E). Validation checklists will be reviewed by the Administrator or designee. Audit records will be reviewed by the Risk Management/Quality Assurance Committee until such time as consistent substantial compliance has been achieved, as determined by the committee.