Failure to Maintain Safe, Sanitary, and Comfortable Environment
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, as required by regulation. Multiple residents experienced prolonged periods without functioning air conditioning in their rooms, despite documented work orders and repeated resident complaints. Residents dependent on oxygen and with significant medical conditions, such as heart failure and chronic respiratory issues, were observed in uncomfortably warm rooms, relying on fans for cooling. Maintenance staff confirmed that repairs were not completed due to unavailable parts and lack of assistance, and residents reported not seeing maintenance staff after initial contact. Environmental cleanliness and maintenance were also lacking throughout the facility. Several resident rooms were observed with dirty, sticky floors, rusted sinks, stained toilets, and built-up grime in corners and on fixtures. In some cases, furniture and call lights were damaged or inadequately repaired, and residents expressed dissatisfaction with the cleanliness and condition of their living spaces. The facility's A unit had widespread blackened buildup at room entryways and corners, and there was no written plan for floor replacement or deep cleaning. Resident council meeting minutes corroborated ongoing concerns about inadequate room cleaning. Common areas and shared facilities were similarly affected. The A unit shower room was repeatedly reported as uncomfortably cold by residents, with a measured temperature below the recommended range, a non-functioning wall heater, and significant dust and debris buildup on ceiling fans and louvers. Dining room chairs were found to be broken or worn, with exposed, unsealed wood surfaces, and at least one chair remained in use despite being identified as unsafe. Maintenance staff confirmed these issues and stated that some problems were not reported to them, resulting in delays or lack of repairs.
Plan Of Correction
F921 The facility failed to maintain a homelike environment for residents #3, #7, #8, #14, #29, #37, #38, #39, #198 directly and all 26 residents on A Wing when: A) 2 PTAC room units (HVAC) stopped working appropriately in residents #198 and #38 rooms. B) Resident #29 toilet dirty, sink rusted, and floors dirty/sticky. C) Resident #39 bed remote needing replaced, the floor was sticky, the light above the sink needed replaced, and the light cover was yellowed. Toilet caulking around toilet stained. D) Resident #8 sink rusted, light over sink yellowed, bathroom floor tiles stained, metal hinges on toilet seat dirty, gouges in bathroom doorway paint. E) Resident #3 floors with buildup in corners, gouges in drywall, tape on call light, bathroom floor with stains, toilet with yellowish stains, furniture in disrepair, unable to use over-the-bed light due to length of string, dust on lights/bulbs. F) Resident #37 toilet with yellowish stains and sticky floor. G) A Wing Shower Room 69 degree ambient temperature with non-functioning heater and fan louvers with build-up. H) All resident rooms on A Wing with buildup of blackened material at threshold to hallway. I) Resident #14 missing/damaged wallpaper near bed. J) One chair in main Dining Room with damaged armrest, remaining chairs with protective finish removed due to wear and in overall disrepair. Step 1: The facility immediately A) replaced the PTAC units in the rooms of both resident #198 and #38, in addition to placing order with contracted maintenance company BIS to assess, secure parts, and/or order additional units. Completed 6/5/25. B) The Maintenance Director audited resident rooms/bathrooms to identify a priority schedule for installation of new flooring, replacement of lighting units, toilets, and sinks. Completed on 7/10/25. C) The toilets in question were immediately cleaned. Completed on 6/10/25. D) DOM will create a schedule for installation of new flooring into non-priority rooms/areas as well as replacement of lighting units, sinks, and toilets. Completed on 7/10/25. The Maintenance Director has initiated repairs to identified areas noted above including the following measures: B) Resident #29 toilet cleaned 6/10/25, sink plan to replace, floors cleaned 6/10/25. C) Resident #39 bed remote needing replaced completed 6/10/25, the floor was sticky and cleaned 6/10/25, the light above the sink needed replaced and the light cover was yellowed both replaced 6/10/25, toilet caulking around toilet stained plan to replace. D) Resident #8 sink rusted plan to replace, light over sink yellowed replaced 6/10/25, bathroom floor tiles stained plan for new flooring, metal hinges on toilet seat dirty cleaned 6/10/25, gouges in bathroom doorway paint, plan to repaint. E) Resident #3 floors with buildup in corners cleaned 6/10/25, gouges in drywall repaired 6/4/25, tape on call light removed 7/10/25, bathroom floor with stains plan to replace, toilet with yellowish stains plan to replace, furniture in disrepair plan to replace, unable to use over-the-bed light due to length of string replaced 7/10/25, dust on lights/bulbs cleaned/dusted 7/10/25. F) Resident #37 toilet with yellowish stains plan to replace and sticky floor cleaned 6/10/25. G) A Wing Shower Room 69 degree ambient temperature with non-functioning heater and fan louvers with build-up corrected 6/4/25. H) All resident rooms on A Wing with buildup of blackened material at threshold to hallway, adhesive from new/replaced hallway flooring removed 7/10/25. I) Resident #14 missing/damaged wallpaper near bed, plan to remove paper and paint room. J) One chair in main Dining Room with damaged armrest removed from use, remaining chairs with protective finish removed due to wear and in overall disrepair, plan to replace all Dining Room chairs. Step 2: This has the potential to affect all residents. The DOM or designee will create a Master Deep Cleaning schedule for all resident rooms/bathrooms/shower rooms. The LNHA will place a request for capital funds to replace sinks, toilets, and furniture identified as in disrepair. Will be completed on 7/10/25. Step 3: To prevent this from recurring, the LNHA, DOM, or designee will educate staff on the work order process. The DOM will educate the environmental services staff on the Master deep cleaning schedule. The DON will educate STNA's on the need for cleaning toilets and floors throughout the day and night when soiled. Completed on 7/11/25. Step 4: To monitor and maintain ongoing compliance, the LNHA or designee will audit 5 rooms for repair/maintenance needs 5 times per week and complete work order notifications. The DON will audit 8 toilets weekly for 4 weeks then monthly for 2 months. The DOM will audit 6 HVAC vents weekly for 4 weeks then monthly for 2 months. Audits to begin on 7/14/25. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.