Failure to Maintain Safe, Clean, and Homelike Environment for Residents
Penalty
Summary
Surveyors identified multiple deficiencies related to the facility's failure to provide a safe, clean, comfortable, and homelike environment for residents across all three residential units. One resident was unable to hang clothing in their closet for over six months due to a missing closet bar, despite repeated requests by the resident's family representative to both the Director of Social Work and the Director of Maintenance. The Director of Social Work recalled discussing the issue at a care plan meeting and with maintenance, but could not confirm if a formal work order was submitted, while the Director of Maintenance did not recall the request. Another resident reported the loss of approximately $45 from their wallet, which was kept on their bedside table. This resident was not provided with a lock box and was unaware of what a lock box was, although the Director of Social Work stated that lock boxes were offered and discussed at resident council meetings, but could not confirm if this resident had been offered one. Environmental observations revealed that heating and air conditioning radiator units throughout the facility were heavily soiled with dust, debris, and black stains, and had bent, crushed, and rusty conductor fins. Several rooms and dayrooms on all floors were affected. Additionally, one room was missing closet doors, leaving clothing exposed. The 3rd Floor dayroom was found to have inadequate lighting, with only a portion of ceiling fixtures illuminated during resident activities and meals, resulting in a dim environment. The 3rd Floor was also noted to be noisy due to a defective call bell system that emitted a continuous beeping noise, which was audible throughout the unit and originated from a wall-mounted intercom near the medication room. The Director of Plant Operations confirmed the beeping was constant and had not been resolved by the call bell vendor. The facility lacked a formal system to track maintenance and repair requests, relying instead on logbooks and verbal communication between staff and the Director of Plant Operations. Maintenance staff were responsible for addressing issues, but there was no documentation to indicate when repairs were completed or if outside vendors were needed. Housekeeping was responsible for cleaning radiator units quarterly, but observations indicated this was not sufficient to maintain cleanliness. The ongoing environmental and safety issues were not addressed in a timely or effective manner, resulting in a failure to uphold residents' rights to a safe and homelike environment.