Observations
Based on a physical plant inspection, conducted on September 19, 2023 between 9:30 AM and 12:30 PM, the facility failed to maintain each bathroom in a functional, clean, and sanitary manner at all times.
Both of the bathrooms in room #'s 339 and 336 had what appeared to be mold/mildew/dirt present.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will been retrained and disciplined for strict adherence to cleaning protocols with proper chemicals and tools. Follow up includes make sure that staff understand the importance of cleaning the showers properly and that they have the knowledge and skills necessary to do so.
-All shower caulking will be removed followed by applying new caulking
EVS supervisor will conduct weekly rounds on all unit showers and by tracking the satisfaction rates among patients and staff. This will be monitored for two months for 100% compliance
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