Failure to Maintain Clean and Safe Physical Environment
Penalty
Summary
The facility failed to effectively clean and maintain the physical plant, impacting 83 residents. During environmental tours of various facility areas, surveyors observed multiple instances of unaddressed soiling, damage, and maintenance issues. These included missing or damaged cabinet components, soiled ventilation grills, stained and warped ceiling tiles, loose or damaged commode seats and supports, leaking plumbing, and soiled or damaged flooring. Additionally, equipment such as microwaves and box fans were found to be corroded or heavily soiled, and air filters in PTAC units were observed with accumulated dust and dirt. In several resident rooms, commode base caulking was found to be etched, scored, stained, or particulate, and some hand sinks were draining slowly or not at all. Interviews with the Director of Maintenance and Housekeeping Director revealed that while a work order system (TELS) was in place, many of the observed deficiencies had not been entered into the system or addressed. For example, missing flooring tiles in a janitor closet had been unaddressed since June 2022, and no work orders were found in the TELS system for the specific maintenance concerns identified during the survey. Staff acknowledged the issues when pointed out and indicated intentions to submit work orders, but these actions had not occurred prior to the survey. A review of the facility's housekeeping policy indicated that cleaning of non-carpeted floors and other horizontal surfaces should occur daily and more frequently if visibly soiled. However, the observations made during the survey demonstrated that these procedures were not consistently followed, as evidenced by the widespread presence of dust, dirt, stains, and damaged surfaces throughout both common and resident areas. The lack of effective cleaning and maintenance increased the likelihood of cross-contamination, bacterial harborage, and decreased air quality for residents, staff, and the public.