Failure to Maintain Clean, Safe, and Homelike Environment and Manage Noise Levels
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for multiple residents, as evidenced by repeated observations of unaddressed environmental hazards and unclean conditions. During facility tours, surveyors observed a handrail with a hole and sharp, jagged plastic outside a resident room, as well as another cracked handrail, both of which maintenance staff were unaware of and had not been documented for repair. The work order system was not being properly utilized, with maintenance staff relying on verbal requests rather than written documentation, resulting in needed repairs being overlooked. Additionally, a weight scale in the family lounge had a torn and flaking grip pad that had not been addressed despite being visible to maintenance staff. Several residents' rooms and equipment were found to be unclean over multiple days. One resident's bedside commode had a dried-brown substance resembling fecal matter on its frame, which was not properly cleaned by staff and remained soiled for several days. Another resident's straight-backed chair had a brown streak resembling fecal matter smeared on the seat, which housekeeping staff acknowledged was a recurring issue. A third resident reported that her bedside commode was full of urine and feces, with urine spilled onto the floor, and that it had not been emptied or cleaned for several hours despite her being cognitively intact and able to report the issue. The Director of Nursing and Regional Clinical Consultant confirmed that staff were responsible for regularly checking and cleaning commodes, regardless of the resident's level of independence. Noise levels at night were not adequately managed, affecting residents' ability to rest. Two residents reported being repeatedly disturbed by a vocal resident across the hall, with one stating he was unable to sleep and had not been offered earplugs or other interventions to reduce the noise, despite the facility having such items available. Staff confirmed that the noisy resident was routinely awake and vocal at night, and that other residents had complained about the noise. Additionally, privacy curtains in two residents' rooms were observed to be soiled with a dried, reddish-brown liquid, and residents expressed concern that these were not promptly cleaned or removed. Facility policy required a clean, comfortable, and homelike environment, including cleanliness and comfortable noise levels, but these standards were not met.