Failure to Maintain Clean and Safe Environment Due to Inadequate QA and Maintenance Tracking
Penalty
Summary
The facility failed to maintain a clean, sanitary, and safe physical environment as required, as evidenced by multiple observations and staff interviews. During a survey, black growth was observed on the floor of a shower room, which a CNA had previously noticed and reported to a nurse, but the issue remained unresolved. The Housekeeping Director confirmed that while the shower room equipment had been pressure washed, there was no documentation or logs to verify when this cleaning occurred. Additionally, the facility lacked a system or log for tracking rooms or items needing cleaning, relying instead on direct verbal reports to the Housekeeping Director. Further deficiencies were identified in the maintenance of resident rooms, including loose sinks, loose toilets, and damaged bed lamination. The Maintenance Director was unaware of some of these issues, despite residents having reported them directly to him. Review of work orders did not show documentation for all reported problems, and the Maintenance Director admitted that he often could not enter work orders immediately when residents reported issues in passing. This lack of timely documentation and follow-up resulted in unresolved maintenance concerns. Interviews with the NHA and Regional President revealed that the facility's process for ensuring environmental cleanliness and maintenance relied heavily on informal communication and random checks, rather than systematic tracking and documentation. Staff were expected to report issues into the facility's maintenance system, and while training on this process had been provided, there were still gaps in execution. As a result, several environmental deficiencies persisted, including unresolved bio-growth in shower areas and unrepaired fixtures in resident rooms.