Observations
Based on a physical plant inspection conducted on January 24, 2024, the facility failed to keep the grounds of the facility in good repair at all times for the safety and well-being of residents, employees and visitors.
Rm # 216 was observed to have the shower frame detached from the wall in the top let corner.
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Plan of Correction
The shower in room #216 has been repaired by the Facilities Director on 1/25/2024.
Moving forward, Facilities Director will be responsible for overseeing and ensuring that thorough walkthroughs are being completed on a monthly basis to identify any repairs that are needed. Repairs needed will then be completed by the facilities team. |
Observations
Based on a physical plant inspection conducted on January 24, 2024, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
Rm # 103, 105, 107, 213,215,216,220,226,227 and 228 were observed to have a black mold like substance in the corner of the shower stalls near the shower basin.
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Plan of Correction
On 2/1/24, five of the showers that were identified to have a "black mold like substance" were properly tested for mold. It takes 10-14 days to receive the results of that testing. If the results in any shower are positive, the facilities department will utilize a certified mold remediation company to address every single shower in the facility.
Regardless of whether the mold test results are positive or negative, Retreat will do the following to ensure that the showers remain functional, clean, and sanitary.
By March 1st, 2024, every shower will be power washed with a Kaivac power washer that is specifically designed to clean hard to clean surfaces, such as the tile showers at Retreat. After each shower is power washed, they will be scrubbed by hand with both Scotch scrubbing pads and a brush for corners. Finally, the shower tiles will be re-caulked where needed. This will be completed by our facilities department with support from Patterson cleaning crew.
Subsequent to March 1st we will power wash the showers on a monthly basis.
Effective 1/25/2024, every patient bathroom will be inspected on a daily basis for structural issues (broken showers, etc), along with any cleanliness issues. This will be a combination of facilities, BHTs, and the cleaning crew. Any issues that arise outside of our thorough monthly walkthroughs will be reported through our help desk system and addressed immediately by the appropriate department, whether it be the cleaning crew or facilities department. The Facilities Director and the BHT Administrator will be responsible for ensuring these daily walkthroughs take place.
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