Failure to Maintain Clean, Orderly, and Odor-Free Environment
Penalty
Summary
The facility failed to maintain a clean, orderly, and well-repaired environment, with multiple observations of detached or damaged baseboard guards in resident bathrooms and hallways, exposing boiler pipes and leaving unfinished, jagged walls. Maintenance staff relied on other staff to report issues through an app, and several maintenance concerns were identified but not yet addressed at the time of the survey. These environmental deficiencies were directly observed in specific rooms and common areas. Persistent urine odors were noted in several rooms and hallways, despite regular cleaning efforts. Housekeeping staff acknowledged that some furniture, such as bed stands, were in poor condition and could not be adequately cleaned, with some items described as dirty and rusty. Staff interviews revealed ongoing challenges in controlling odors, particularly in rooms with residents who were incontinent or uncooperative with care, and there was confusion regarding responsibility for cleaning certain items like wheelchairs and bed stands. Multiple residents with significant medical histories, including Alzheimer's disease, dementia, stroke, and incontinence, were observed in unclean environments. Specific observations included residents lying in beds with urine-soaked linens, food debris on sheets and floors, dirty dishes left in rooms, and dark, unkempt living spaces. In some cases, residents refused removal of dirty items, and staff reported difficulties in maintaining cleanliness due to resident behaviors and the condition of facility furnishings.