Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0100
Based on observation and interview, the facility failed to maintain general requirements that are not addressed by the provided K-tags, but are deficient, affecting the entire building.
Findings include:
Observation on January 22, 2026, at 10:25 a.m., revealed the facility failed to submit plans to State Plan Review and receive a granted occupancy from the Life Safety Division for the change of use of the 400-wing resident rooms and the soiled utility room. Christmas trees, boxes, and furniture were being stored in unoccupied wing.
Interview with the maintenance supervisor on January 22, 2026, at 10:25 a.m., confirmed the deficiency at the time of the survey.
| | Plan of Correction - To be completed: 02/22/2026
This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because Communities at Indian Haven agrees with the allegations and citations listed on the statement of deficiencies. Communities at Indian Haven maintains that the alleged deficiencies do not, individually, and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Communities at Indian Haven's written credible allegation of compliance. By submitting this plan of correction, Communities at Indian Haven does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Communities at Indian Haven reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding.
The 400-wing resident rooms and soiled utility room will be cleared to contain only resident furnishings and assistive devices.
The Environmental Services Director and Maintenance Technician and/or designees will remove items that were stored on the unoccupied 400-wing resident rooms and utility room.
The Environmental Services Director or designee will complete random audits weekly for 4 weeks and monthly for 2 months to assure that the 400-wing is maintained with furnishings and assistive devices. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee.
|
