Inspection Findings:
Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair. Findings include, but are not limited to:Observations of the facility on 01/24/23 through 01/25/23 showed the following areas in need of cleaning or repair:* Multiple walls on both floors had scrapes, chipped paint, drips or gouges;* Multiple dining room tables and chairs had large sections where the finish was significantly worn or gone. Chair arms and table legs had scrapes and gouges;* The cupboards, drawers and walls in the activity room had spills, stains and splatters. The refrigerator had spills inside the refrigerator, along the front grate and debris was on the bottom shelf;* The bathroom in the activity room had chipped counter top edges, missing and cracked laminate flooring and a large section of flooring that was pulling apart with a large gap between the two pieces of flooring;* Scrapes, dings and deep gouges were noted on doors, door frames or nearby walls at rooms 102, 103, 104, 113, 122, 123, 142, 143, 147, 151, 156, 157, 222, 241, 247, 251 and 252;* Window sills in the dining room, activity room and sitting room on the second floor had stains, debris, dead insects, bubbling and/or peeling paint or spills; * The main laundry room was noted to have multiple large scrapes across doors and walls, the small washing machine had dark accumulation at the back of the machine on top of and behind the lid and walls had deep gouges and scrapes with pieces of drywall or plaster missing. Cupboards and drawers had debris on the shelves and spills/stains to the fronts and insides;* The activity room, the area in front of the kitchen, the hallway alcove across from the kitchen, in front of the main laundry room, in front of the dining room and in front of rooms 223 and 224 had dark stains to the carpet of varying sizes;* Two brown banquet tables in the hallways had long scrapes and gouges across the table top and along the edges.The areas in need of cleaning and repair were reviewed with Staff 1 (Executive Director) on 01/24/23. She acknowledged the findings.
Plan of Correction:
1. All walls with scrapes, chipped paint, drips or gouges are being repaired. New dining room chairs, and tables will replace the old chairs and tables. Detailed cleaning of the activity room food area was performed immediately. In the Activity Area Bathroom a new countertop has been ordered. Flooring will also be replaced in the same bathroom. All scrapes, dings, and deep gouges on downstairs doors in process of being repaired. All window sills in common areas noted have been cleaned and repaired. Repairs and deep cleaning were performed in the main laundry room. Stains in carpet noted upstairs in front of #223 & #224 have been treated and removed, also stains in front of main laundry room and dining room have been treated and are in the process of being removed. New brown banquet tables have been ordered to replace the damaged. 2. The system was corrected by formal replacement of maintenance director.3. The area(s) in need of correction will be evaluated weekly and then monthly thereafter. 4. Staff #1 ED will monitor corrections and work directly with maintenance director to see that the ongoing repair and replacement efforts are being completed.