Observations
Based on a physical plant inspection of the bathroom in client bedroom 218, the facility failed to maintain the bathroom in a clean and sanitary manner.
During a complaint investigation conducted on February 23, 2022, the bathtub and radiator in the bathroom appeared to contain rust. Also, a black substance which appeared to be mold was observed around the bathtub.
In addition, the radiator under the window in the bedroom had stains that appeared to be rust. A black substance which appeared to be mold was observed around the trim throughout the bedroom. Broken baseboard trim was observed to be broken in multiple areas exposing sharp edges and more of the black mold-like substance. The pipes near the ceiling appeared to be rusted and white paint was chipped off. A loose wall panel was observed near the bathroom door under the bedroom window.
This was discussed with facility staff during the complaint investigation.
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Plan of Correction
Citations Response:
1. Rust-like substance on radiator in the bathroom removed & radiator painted. Coating applied to the rust in the bathtub. Within 6 months, the bathtub will be removed during renovations. Director of Plant Maintenance responsible for the cleaning & the Executive Director for renovations.
2. Black substance cleaned around the bathtub. Rust-like substance removed from radiator under the window in the bedroom & radiator repainted. Director of Plant Maintenance responsible for cleaning, repair, and painting.
3. Electric wire mold around the trim of the bedroom was cleaned & re-painted. Black substance easily removed with cleaning. Director of Plant Maintenance responsible for cleaning, repair, and renovation.
4. Cove bar (baseboard trim) replaced throughout the room, no sharp edges remaining. Area with black substance cleaned. Director of Plant Maintenance responsible for cleaning, repair, and renovation.
5. Sprinkle pipe cleaned, rust-like substance removed, and pipe repainted. Director of Plant Maintenance is responsible for cleaning, repair, and renovation.
6. Panel near the bathroom door and under the bedroom window were secured. Director of Maintenance responsible for securing panel.
In addition:
- Housekeeping staff will report any housekeeping and/or plant maintenance issues as needed to the Director of Plant Maintenance. Housekeeping staff will be educated by Director of Plant Maintenance on identifying issues of concern by April 15, 2022. The Director of Plant Maintenance will then submit an electronic ticket for anything reported and assign the task to a maintenance employee.
- Environmental rounds will be completed quarterly by PI Coordinator and include, at a minimum, the Director of Plant Maintenance & Executive Director or designee, to ensure cleaning and renovation concerns are identified and repaired.
- The PI Coordinator will ensure corrective action above is implemented.
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