Failure to Maintain Safe, Clean, and Well-Maintained Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and well-maintained environment for all residents, as evidenced by multiple observations of unsanitary and hazardous conditions throughout the building. Surveyors documented the presence of brown sticky substances, dirt, debris, dried feces, and urine in resident rooms and restrooms. Several rooms had toilets that were not functioning, with signs indicating they were out of order, and plumbing issues were reported by both staff and residents. Floors and cove bases were observed with significant buildup of dirt, stains, and residue, and in many areas, the flooring was damaged, with missing or broken tiles, chipped concrete, and uneven surfaces. These conditions were present in both private and common areas, including shower rooms, hallways, and the dining room, where missing cove base and crumbling drywall were also noted. Interviews with residents, staff, and the ombudsman confirmed ongoing concerns about the cleanliness and maintenance of the facility. Residents reported seeing mice, dead insects, and flies, and expressed distress about the state of their living environment. Staff members, including CNAs and housekeepers, stated that the facility was filthy, that plumbing frequently backed up, and that housekeeping was unable to keep up with the cleaning demands due to persistent maintenance issues. The Housekeeping/Laundry Supervisor and other housekeepers indicated that the floors required stripping and scraping, but there was no dedicated floor technician, and management was aware of these issues but had not taken sufficient action. The ombudsman and a resident's power of attorney also reported repeated complaints to facility leadership about the poor condition of the building and lack of timely repairs. Additional hazards were observed, such as exposed electrical wires, missing light fixture covers, poorly lit hallways, loose hand railings, and damaged furniture. Mold and black residue were noted in shower rooms, and a large fan covered in dust was found blowing air onto the food preparation area in the kitchen. Facility records, including Resident Council minutes and the facility's own policy, documented that maintenance and housekeeping were understaffed and unable to keep up with the required upkeep. The facility's failure to address these environmental deficiencies affected all residents, including those who were cognitively intact and able to articulate their concerns, as well as those with cognitive impairments.