Failure to Maintain Safe, Clean, and Homelike Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for four residents in the memory unit, as evidenced by multiple observations and interviews. Resident rooms were found to be inadequately cleaned and maintained, with specific issues such as missing or broken fixtures, unpainted and damaged walls, holes in doors, and the presence of food particles and soiled items on the floor. For example, one resident's room had a cracked sink, missing hot water knob, unpainted areas with holes, and brown sticky substances on the floor. Another resident's room contained broken ceiling tiles, soiled toilet paper on the floor, broken blinds, and food debris on various surfaces. Staff interviews revealed that the residents in question had significant cognitive impairments, including dementia, encephalopathy, and schizoaffective disorders, and some exhibited behaviors such as destroying furniture and throwing items on the floor. Despite these known behaviors, staff and housekeeping did not consistently ensure that rooms were cleaned as needed. Housekeeping staff reported only cleaning the memory unit once per day, typically at the end of their shift, and stated that the workload was too great for one person. Staff also indicated that they had notified supervisors about the need for repairs and cleaning, but maintenance and housekeeping supervisors claimed they were unaware of the specific issues. Facility records showed no work orders for repairs or replacement of blinds, fixtures, or wall repairs in the memory unit during the relevant period. The facility's own policy required that rooms be maintained in a safe, functional, and comfortable condition, with all staff responsible for reporting and addressing maintenance and cleanliness issues. However, these policies were not followed, resulting in residents living in rooms that were not thoroughly cleaned or properly maintained.