Observations
Based on a physical plant inspection conducted during a complaint investigation on February 7, 2023, the facility failed to ensure the safety and well-being of clients, staff and visitors as evidenced by the following:
Rm # 321 had paint chipping off the chair rail, damage to drywall, a nail sticking out of air conditioning unit and broken window blind.
Rm # 322 had wallpaper peeling off the wall.
Rm # 323 had a substantial amount of ceiling paint hanging from the ceiling, chipped paint on the windowsill and wallpaper peeling off.
Rm #324 had ceiling paint chipping and hanging from ceiling, chair rail paint chipped and a chair with torn material hanging from the bottom.
Rm # 325 had drywall missing behind sink, wallpaper peeling from the wall and a broken window blind.
Rm # 326 had wallpaper peeling off the wall.
Rm # 327 had a large section of wallpaper is not adhered to the wall properly and chipped paint on chair rail.
Rm # 328 had chipped paint on the windowsill and chair rail and wallpaper peeling off the wall. It also had rust on the radiator
Rm # 329, a broken free-standing closet, broken, loose and cracked floor tile and vents missing from the air conditioner.
Rm #330 had loose and missing baseboard, drywall separating from the wall, wall is cracked around chair rail along with a cracked chair rail, a broken window and wallpaper not properly adhered to the wall.
Rm # 331 had chipped paint on chair rail, a missing closet door, wallpaper peeling off the wall and broken and loose floor tiles.
Thrid floor hallway near Rm 330, 331 has an uneven floor causing linoleum to buckle and crack. Also, the wallpaper wall peeling off the wall outside room 326.
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Plan of Correction
Based on a physical plant inspection conducted during a complaint investigation on February 7, 2023, the facility failed to ensure the safety and well-being of clients, staff and visitors as evidenced by the following:
Rm # 321 had paint chipping off the chair rail, damage to drywall, a nail sticking out of air conditioning unit and broken window blind.
As of 2/24/23, the maintenance staff has completed painting the drywall and paint that was chipping was removed and re-painted. In addition, the nail in the air conditioning unit has been removed and the blinds have been replaced. This has been verified by the Facilities Director, and the Director of QA. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a logbook will be maintained to note any repairs, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director.
Rm # 322 had wallpaper peeling off the wall.
As of 2/24/23, the maintenance staff has re-glued the peeling wallpaper and the paper is now laying flat on the wall surface. This has been verified by the Facilities Director, and the Director of QA. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a logbook will be maintained to note any repairs, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director.
Rm # 323 had a substantial amount of ceiling paint hanging from the ceiling, chipped paint on the windowsill and wallpaper peeling off.
In Room 323, the ceiling paint has been stripped and the chipped paint on the windowsill has been removed. Both the ceiling and the windowsill have been re-painted. The peeling wallpaper has been re-glued to the drywall. This was completed by the maintenance staff on 2/24/23. This has been verified by the Facilities Director, and the Director of QA. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a logbook will be maintained to note any repairs, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director.
Rm #324 had ceiling paint chipping and hanging from ceiling, chair rail paint chipped and a chair with torn material hanging from the bottom.
In Room 324, the maintenance crew completed the following repairs as of 2/24/23. The ceiling and the chair rail have had the chipped paint removed and have been repainted. The chair with the torn material hanging from the bottom has been removed and replaced with a chair in acceptable condition. This has been verified by the Facilities Director, and the Director of QA. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a log book will be maintained to note any repairs, and the condition of furniture, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director.
Rm # 325 had drywall missing behind sink, wallpaper peeling from the wall and a broken window blind.
In Room 325, the maintenance crew has replaced the dry wall behind the sink, as of 2/24/23. In addition, the peeling wallpaper has been re-glued to the wall, this was also completed by 2/24/23. The window blinds were replaced on 2/23/23. This has been verified by the Facilities Director, and the Director of QA. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a logbook will be maintained to note any repairs, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director.
Rm # 326 had wallpaper peeling off the wall.
Room 326 wallpaper has been re-glued as of 2/24/23, by the maintenance crew. This has been verified by the Facilities Director, and the Director of QA. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a logbook will be maintained to note any repairs, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director.
Rm # 327 had a large section of wallpaper is not adhered to the wall properly and chipped paint on chair rail.
In Room 327, the wallpaper has been re-glued to the wall, and the chair rail chipped paint has been removed and it has been re-painted. This was completed by the maintenance staff and verified on 2/24/23. This has been verified by the Facilities Director, and the Director of QA. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a logbook will be maintained to note any repairs, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director.
Rm # 328 had chipped paint on the windowsill and chair rail and wallpaper peeling off the wall. It also had rust on the radiator.
In Room 328, the chipped paint on the windowsill was removed and re-painted. The wallpaper was re-glued to the drywall and the rust on the radiator was removed, sanded and painted. This work was completed by the maintenance staff and verified on 2/24/23. This has been verified by the Facilities Director, and the Director of QA. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a logbook will be maintained to note any repairs, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director.
Rm # 329, a broken free-standing closet, broken, loose and cracked floor tile and vents missing from the air conditioner.
In Room 329 the free-standing closet has been fixed. The broken, loose and cracked floor tiles have been replaced, as of 2/24/23. The Facilities Director will evaluate the air conditioner within 15 days and determine the course of action. The vents on the air conditioner will be placed or repaired by 3/24/23. This work was completed by the maintenance staff. This has been verified by the Facilities Director, and the Director of QA. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a logbook will be maintained to note any repairs, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director.
Rm #330 had loose and missing baseboard, drywall separating from the wall, wall is cracked around chair rail along with a cracked chair rail, a broken window and wallpaper not properly adhered to the wall.
In Room 330, the loose baseboard was secured to the wall. The missing baseboard was replaced. The drywall was patched and reconnected to the wall. The wall was spackled, sanded and painted where it was cracked. A section of the chair rail that was broken, was repaired. The wallpaper was re-glued to the wall. This work was all completed by the maintenance crew. The window will be measured and evaluated by the Facilities Director by 3/3/23, to determine if it can be repaired or if it needs to be replaced. Should the window need to be replaced the Facilities Director will order and install the window. An exact time frame cannot be given if replacement is needed, because it is dependent upon availability. The completed work was verified by the Facilities Director, and the Director of QA. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a logbook will be maintained to note any repairs, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director.
Rm # 331 had chipped paint on chair rail, a missing closet door, wallpaper peeling off the wall and broken and loose floor tiles.
In Room 331 the chipped paint on the chair rail was removed and repainted. The peeling wallpaper was reglued to the wall. The broken and loose floor tiles were replaced. This was completed by the maintenance staff and was verified as of 2/24/23. This has been verified by the Facilities Director, and the Director of QA. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a logbook will be maintained to note any repairs, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director.
Third floor hallway near Rm 330, 331 has an uneven floor causing linoleum to buckle and crack. Also, the
The third-floor hallway floor needs to be replaced/repaired. The maintenance staff will assess the floor and determine the best course of correction. They will complete the assessment by 3/3/23. The Facilities Director will order the necessary supplies and complete the repairs by 3/24/23. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a logbook will be maintained to note any repairs, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director.
Wallpaper wall peeling off the wall outside room 326.
The wallpaper outside of room 326 has been reglued to the wall. The maintenance staff completed this work. This was completed by the maintenance and was verified as of 2/24/23. This has been verified by the Facilities Director, and the Director of QA. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a logbook will be maintained to note any repairs, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director.
The bathroom in client bedroom 321 had rust on the heater, pipe and the doorframe and chipped drywall and paint.
In the bathroom of room 321 the rust on the heater, pipe and doorframe have been removed, sanded and painted. The drywall has been patched, repaired and replaced. This was completed by the maintenance staff and was verified as of 2/24/23. This has been verified by the Facilities Director, and the Director of QA. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a logbook will be maintained to note any repairs, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director.
The bathroom in client bedroom 325 had chipped paint and rust on the doorframe.
The bathroom in room 325 the rust on the doorframe was removed, sanded and painted. This was completed by the maintenance staff and was verified as of 2/24/23. This has been verified by the Facilities Director, and the Director of QA. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a logbook will be maintained to note any repairs, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director.
The bathroom in client bedroom 329 was missing shower floor tiles.
The bathroom tiles in room 329 have been replaced. This was completed by the maintenance staff and was verified as of 2/24/23. This has been verified by the Facilities Director, and the Director of QA. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a logbook will be maintained to note any repairs, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director.
The bathroom in client bedroom 330 was missing towel racks, wall tiles, and had paint/other debris hanging from the ceiling vent cover.
The bathroom in room 330 has had the towel racks and wall tiles replaced. The ceiling vent cover was removed, and the debris was cleaned. The vent cover was reinstalled. This was completed by the maintenance staff and was verified as of 2/24/23. This has been verified by the Facilities Director, and the Director of QA. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a logbook will be maintained to note any repairs, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director.
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Observations
Based on a physical plant inspection conducted during a complaint investigation on February 7, 2023, the facility failed to maintain each bathroom in a clean and sanitary manner.
The bathroom in client bedroom 321 had rust on the heater, pipe and the doorframe and chipped drywall and paint.
The bathroom in client bedroom 325 had chipped paint and rust on the doorframe
The bathroom in client bedroom 329 was missing shower floor tiles
The bathroom in client bedroom 330 was missing towel racks, wall tiles, and had paint/other debris hanging from the ceiling vent cover.
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Plan of Correction
The bathroom in client bedroom 321 had rust on the heater, pipe and the doorframe and chipped drywall and paint.
In the bathroom of room 321 the rust on the heater, pipe and doorframe have been removed, sanded and painted. The drywall has been patched, repaired and replaced. This was completed by the maintenance staff and was verified as of 2/24/23. This has been verified by the Facilities Director, and the Director of QA. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a logbook will be maintained to note any repairs, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director.
The bathroom in client bedroom 325 had chipped paint and rust on the doorframe.
The bathroom in room 325 the rust on the doorframe was removed, sanded and painted. This was completed by the maintenance staff and was verified as of 2/24/23. This has been verified by the Facilities Director, and the Director of QA. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a logbook will be maintained to note any repairs, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director.
The bathroom in client bedroom 329 was missing shower floor tiles.
The bathroom tiles in room 329 have been replaced. This was completed by the maintenance staff and was verified as of 2/24/23. This has been verified by the Facilities Director, and the Director of QA. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a logbook will be maintained to note any repairs, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director.
The bathroom in client bedroom 330 was missing towel racks, wall tiles, and had paint/other debris hanging from the ceiling vent cover.
The bathroom in room 330 has had the towel racks and wall tiles replaced. The ceiling vent cover was removed, and the debris was cleaned. The vent cover was reinstalled. This was completed by the maintenance staff and was verified as of 2/24/23. This has been verified by the Facilities Director, and the Director of QA. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a logbook will be maintained to note any repairs, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director.
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