Failure to Maintain Safe and Homelike Environment in Resident Units
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment on two out of four resident units. On Unit 2, eight out of 22 resident rooms and the activity room were found with issues such as gouges in the walls, nonfunctional or missing nightlight covers, holes and scrapes in doors and walls, clogged sinks, dented heating vents, and exposed wiring. On Unit 4, all 19 resident rooms had similar deficiencies, including gouges and holes in walls, torn wallpaper, missing or exposed electrical outlet covers, missing floor tiles, and holes from door handles. These environmental issues were directly observed by surveyors during their walkthroughs. Interviews with the Unit Manager revealed that maintenance issues are supposed to be documented in a log book accessible to all staff, and the Maintenance Director is expected to review these logs during daily rounds. However, a review of the maintenance log books for the affected units showed no documented requests for repairs related to the observed deficiencies in the past 90 days. The Maintenance Director confirmed awareness of some issues but indicated that materials needed to be ordered for repairs. Despite the process in place for reporting and addressing maintenance concerns, the lack of documentation and follow-up resulted in ongoing environmental problems. During a Resident Council Group interview, the majority of residents expressed ongoing frustration with the facility environment, citing persistent issues such as holes in walls, broken heating vents, and bathrooms needing repairs. Residents reported that these problems had not been addressed despite being present for some time. The facility administration acknowledged that renovation and remodeling projects were only partially complete and that there had been no quality improvement project focused on environmental repairs for the affected units prior to the survey.