|§483.90(i) Other Environmental Conditions|
The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.
Based on observations and staff interviews, it was determined that the facility failed to maintain a safe and sanitary environment for residents and staff.
Observations in the shower room on the 100 hall on February 21, 2020, at 6:46 a.m. and 7:48 a.m. revealed that a 2 x 24 inch metal corner bead on the wall dividing the shower stall nearest the door from the tub area had pulled away from the wall due to the tile under the corner bead being broken. Both upper corners of the corner bead were protruding outward from the wall and had sharp, pointed corners. There were five 8 x 6 inch tiles in the shower stall nearest the toilet that were cracked and broken approximately three inches above the floor, leaving sharp edges, and the shower stall nearest the door had one 8 x 6 inch tile that was cracked/broken approximately three inches above the floor, leaving sharp edges.
Interview with the Regional Director of Maintenance on February 21, 2020, at 12:10 p.m. confirmed the above conditions in the shower room on the 100 unit and confirmed that the pointed corners and sharp tile edges were safety hazards.
Observations on February 21, 2020, between 6:17 a.m. and 10:53 a.m. revealed the following:
The heating vent in the lower section of the wall near the toilet in the 200 unit shower room had an accumulation of dust in it. The heating unit in the main dining room annex had a black and gray, removable substance on the interior plastic section of the vents. There was an accumulation of dust, food crumbs, and candy under the vending machines in the lounge on the 100 unit. The heating units in the following resident rooms had accumulations of dust, dirt, debris, and cobwebs either on the outer surfaces and/or on the floor under the units: 101, 104, 105, 107, 108, 109, 110, 111, 112, 113, 114, 115, 116, 117, 118, 120, 124, 125, 127, 128, 129, 130, 131, 201, 202, 203, 206, 209, 210, 211, 212, 215, 216, 217, 219, 221, 222, 223, 224, 225, 228, 229, 230, 231, 232, and 233. There was also an accumulation of dust and debris under the heating unit in the activity room, as well as under all three heating units in the therapy suite.
Interview with the Laundry/Housekeeping Supervisor on February 21, 2020, at 1:18 p.m. confirmed that the above areas needed cleaned. She stated that there possibly was a miscommunication between housekeeping and maintenance as to whose responsibility it was to clean the heating units.
28 Pa. Code 207.2(a) Administrator's responsibility.
| ||Plan of Correction - To be completed: 04/21/2020|
1. Actions taken for the situation identified:
No residents were affected by the noted areas in the shower room or heating units. The sharp edges in the shower room have been covered as a stop gap measure until a permanent solution can be completed. The facility is actively seeking bids to refurbish the north wing shower room. The identified heating units are being cleaned and a routine cleaning and preventative maintenance schedule has been developed.
2. How the facility will act to protect residents in similar situations:
The facility recognizes that all residents have the potential to be affected. In addition to completing the necessary maintenance and repairs, the facility has implemented daily manager rounds of specific areas throughout the facility, including resident rooms, the shower rooms and heating units, to monitor, identify and address repair, maintenance, and cleanliness issues throughout the facility.
3. System changes and measures to be taken:
The Administrator or designee will re-educate maintenance and housekeeping staff on the importance of the safety and cleanliness of facility equipment and environment. Daily manager rounds and cleaning schedules have also been implemented to monitor, identify and address repair, maintenance, and cleanliness issues.
4. Monitoring mechanisms to assure compliance:
The Director of Housekeeping or designee will audit heating units for cleanliness weekly for four (4) weeks then monthly for two (2) months. Manager rounds reports will be audited by the Nursing Home Administrator weekly for four (4) weeks and then monthly for two (2) months for completion of maintenance and repair issues. Incidents of non-compliance will be addressed immediately, and audit results will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings and further action plans and audits will continue until substantial compliance is achieved. From then on, monthly Quality Assurance Performance Improvement meetings will help to ensure quality standards are met through continual performance analyses and the implementation of systematic efforts to improve those processes that do not meet acceptable levels. This will include self-monitoring of identified deficient practices that shall be reviewed during the monthly Quality Assurance Performance Improvement Committee meetings, as well as the Quarterly Quality Assurance Meetings, until significant corrections are noted and ongoing, as necessary.
5. Date Corrective Action will be completed:
Substantial compliance is expected by April 21, 2020.