Failure to Maintain Clean and Safe Environment Across Facility Units
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment across two units, as evidenced by multiple observations of unaddressed environmental deficiencies. Surveyors noted dark scuff marks in hallways, heater units with brown and black substances on their surfaces, cracked and missing floor tiles, and broken or misaligned closet doors and dresser drawers. These issues were not consistently documented in the facility's work order system, and some were only tracked informally by the Director of Maintenance/Housekeeping/Laundry (DMHL) on personal lists. Additionally, fluid was observed leaking from ceiling tiles, and the elevator had significant paint peeling and damaged wooden guard rails, with attempts to cover up rather than repair the damage. Further observations included missing floor tiles and discolored ceiling tiles with debris buildup on vents in resident rooms and common areas. Handrails and columns in the nurse's station area were found to be damaged or missing parts, and some of these issues were acknowledged by the DMHL as being difficult to repair due to the age of the building materials. Staff interviews revealed that while some staff attempted to address minor repairs themselves, most relied on the maintenance request system, which was not always effective in ensuring timely repairs. Additional deficiencies included brown stains on ceiling tiles in multiple resident rooms, which persisted over several days of observation. The DMHL acknowledged these issues but indicated they had not yet been added to the maintenance list. Facility leadership confirmed that environmental rounds were conducted by department heads and the DMHL, but also stated that the facility was in the process of being updated and not all repairs could be completed immediately.