Failure to Maintain Safe and Clean Resident Bathroom Equipment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment as required by federal regulations. During facility tours, surveyors observed that three resident rooms (112, 113, and 116) had over-the-toilet seats showing visible signs of rust. These observations were made on two separate occasions. The presence of rusted bathroom equipment indicates a lack of proper maintenance and cleaning, which is necessary to ensure a sanitary and comfortable environment for residents. Interviews with the Director of Maintenance revealed that maintenance work orders are managed on paper, with employees responsible for writing up and submitting issues they observe daily. Although a maintenance inspection sheet exists to guide preventative maintenance and room checks, the Director of Maintenance admitted that these room checks were not currently being performed. Review of facility policies and inspection forms showed that procedures for routine cleaning, disinfection, and room inspections were in place, but the lack of implementation contributed to the deficiency.
Plan Of Correction
Specific Corrective Action A full inspection of all resident rooms was conducted on 7/18/2025, identifying all over the 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 B). 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.