Failure to Maintain Clean, Safe, and Comfortable Resident Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and comfortable environment for its residents, as evidenced by multiple observations of unsanitary and poorly maintained resident rooms. Residents reported and surveyors observed stained sheets, broken or missing furniture handles, holes in walls, non-functioning televisions, water damage, missing baseboards, and broken grab bars in shared bathrooms. Additionally, there were reports of excessive heat due to non-functioning windows, dust and grime on curtains, and persistent unpleasant odors such as urine. Maintenance logs confirmed that many of these issues had been outstanding for several months without resolution. Several residents, including those with complex medical and psychiatric histories such as schizophrenia, bipolar disorder, dementia, and heart failure, expressed dissatisfaction with the cleanliness and repair of their living spaces. Observations included holes in walls, chipped paint, stained pin boards, dirty floors, and buildup on radiator vents and bathroom vents. Residents also reported that maintenance was aware of these issues but had not addressed them, and that housekeeping was insufficient, with visible stains and residue remaining for multiple days. The facility's maintenance and housekeeping policies require prompt attention to repairs and regular cleaning, but interviews with staff revealed gaps in communication and follow-through. The maintenance manager relied on nurse logs and did not routinely inspect all resident rooms, focusing instead on common areas. There was also a lack of clarity regarding work orders, as seen in the case of a resident who waited three weeks for a television after being moved to a new room. The facility's failure to address these environmental deficiencies affected all nine residents reviewed for this issue.