Deficiencies in Resident Privacy, Cleanliness, and Personal Property Management
Penalty
Summary
Multiple rooms on the Evergreen unit were observed to have large windows with white plastic blinds that were missing several slats, allowing visibility into the rooms from outside even when the blinds were closed. Maintenance and housekeeping work order records reviewed over a ten-month period did not show any requests for repair or replacement of these blinds. Staff interviews confirmed that many blinds throughout the building were broken, creating privacy concerns for residents, especially during personal care activities. Facility policy required broken blinds to be repaired or replaced and for audits to be conducted, but these actions were not documented for the affected rooms. Shower rooms throughout the facility were found to be in poor condition, with observations of mold-like black substances, cracked and missing tiles, slimy and discolored surfaces, and unclean fixtures. In several shower rooms, tiles were missing or cracked, exposing bare walls to water, and various colored substances were present on floors, walls, and fixtures. Staff interviews revealed inconsistent knowledge and practices regarding cleaning responsibilities and frequencies, with some staff unsure about the presence of mold or the adequacy of cleaning. The facility's cleaning policy did not specifically address shower rooms, and the Environmental Service Director acknowledged the need for tile replacement and ongoing issues with mold. A resident with multiple chronic health conditions, including alcoholic cirrhosis, hypertension, renal failure, hepatic encephalopathy, and fibromyalgia, reported numerous personal items missing over a period of approximately nine months. The missing items included clothing, jewelry, and personal care products. Interviews with staff indicated that missing item reports were completed and distributed, but there was a lack of follow-up, tracking, or resolution regarding the recovery of the resident's belongings. The facility's policy required thorough investigation, documentation, and follow-up for missing items, but staff were unaware of the need to track or resolve these reports, and the resident had not received updates about her missing possessions.