Observations
Based on a physical plant inspection conducted on November 10, 2014 between 12:00pm and 3:00pm, it was determined that the facility failed to keep the grounds of the facility clean, safe, sanitary, and in good repair at all times for the safety and well being of residents, employees, and visitors.
The findings were:
A physical plant inspection was conducted and the following safety and sanitary concerns were noted.
1. Every bedroom on the 3rd (women's) floor and 4th (men's) floor had a large amount of dust collecting on the mechanical ventilation covers.
2. There was a section on the 3rd floor (women ' s residential floor) that had floor tiles missing and the plywood was exposed. This was identified as being an area that had a leak and based on conversation with the facility director the floor in that area was slated to be fixed in the next week or two.
3. On the 4th floor (men ' s residential floor), there was a section of floor that was identified as a leak area. This section had tiles that were coming up and the plywood flooring underneath was extremely soft, allowing the possibility of someone walking on it to fall through the flooring. The facility director said that this area was also slated to be fixed in the next week or two as well.
4. There were several drawers in the front nurse ' s station that were falling apart and needed to be replaced/fixed.
5. There were ceiling tiles in the nurse ' s stations and throughout the rest of the hallways on both the 3rd and 4th floors that did have old water stains and there was 1 tile identified on the 3rd floor (near the community/group room) that did have mold growing on it.
6. Another item identified was that there were many escutcheon plates (which go around the sprinkler heads) missing throughout the entire building on all floors inspected.
These findings were discussed with facility staff during the complaint investigation process.
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Plan of Correction
The maintenance Department cleaned all ventilation covers on the 3rd and 4th floors on 12/3/14.
The 3rd floor Men's unit and 4th floor Women's unit had floor tiles installed and the sections of the floor where the plywood was exposed has been repaired. The 3rd floor Men's unit floor was repaired on 11/25/14 and the 4th floor Women's unit floor was repaired on 12/2/14.
The drawers in the nurses station were repaired on 12/5/14.
The ceiling tile that was identified on the 3rd floor that appeared to have mold beginning to grow was replaced on the date of the audit 11/10/14. The other tiles were replaced on 11/28/14.
Majek Fire Protection will start replacing the escutcheon plates throughout the facility by 12/11/14.
The residential facility will be monitored daily per DDAP Policy 705.2 Building Exterior and Grounds.
Persons Responsible: Program Director, Operations Supervisor, Maintenance Department, House Manager of Maintenance.
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