Failure to Maintain Sanitary and Safe Resident Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, as evidenced by multiple observations and interviews. Toilets in several resident rooms were not adequately cleaned, with persistent urine odors, wet floors, and visible fecal matter remaining for days. In one case, a resident's wheelchair and cushion were not cleaned regularly, resulting in a strong urine odor that was noticed by family members. Housekeeping staff reported that bathrooms were scheduled for cleaning only on certain days, and there was confusion about who was responsible for reporting and addressing maintenance issues, such as a running and overflowing toilet that was not reported to maintenance or administration. Beds in some rooms were found unmade or only partially made, with bare mattresses or missing blankets and bedspreads. Additionally, window screens were found to be broken or missing for extended periods, with residents reporting that screens had been damaged by housekeeping staff and not replaced for months. Housekeeping and maintenance staff confirmed ongoing issues with cleaning schedules and the replacement of window screens, and documentation showed that some windows had not been cleaned or screens replaced for several months. Electrical safety was also compromised, as one resident reported loose wall outlets that had not been repaired despite being reported to the Maintenance Director months prior. Observations confirmed that plugs for essential medical equipment, such as a CPAP machine, were hanging loosely from the outlets. Staff interviews revealed that there was only one housekeeper on certain weekends, leading to delays in cleaning, and that complaints from residents about cleanliness were known but not always addressed promptly. Facility policies required daily cleaning of toilets, but this was not consistently followed.