Failure to Maintain Cleanliness, Wall Repair, and Handrail Safety
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in several areas, as evidenced by observations in two of four shower rooms and three resident rooms. In the shower rooms, surveyors found multiple issues including opened and used medical supplies left on counters, crumpled paper towels and other debris on the floor, a used finger lancet not properly disposed of, and cabinet doors that were either hanging by a single hinge or missing handles. Personal items such as a blue knit hat and eyeglasses were left in the shower area, and open bottles of body wash and lotion were not properly closed or stored. Staff interviews confirmed that the expectation was for nursing assistants to clean and prepare the shower rooms after each use, but this was not consistently done. In three resident rooms, walls were observed to be in poor condition, with peeling and chipped paint, large scrapes, and unfinished patchwork. One resident reported that the scrapes on the wall had been present for at least a year and that staff were aware but had not addressed the issue. Another resident's room had extensive black markings and torn drywall, as well as peeling paint and staining along the wall. Staff interviews indicated that maintenance work orders were expected to be submitted for such repairs, but there was no evidence that this process was consistently followed. Residents expressed dissatisfaction with the appearance of their rooms, describing the conditions as unsightly and not reflective of a homelike environment. Additionally, a hallway handrail was found to be insecurely attached to the wall, with only one bolt holding it in place, allowing it to spin and rotate freely. Staff and maintenance personnel acknowledged that the handrail was not safe for use and required immediate repair. The facility's policy on environmental cleaning required regular checks of hinges, door facings, and handles, but there was no evidence that policies regarding wall repair and handrail security were provided or followed. These deficiencies were identified through direct observation, resident and staff interviews, and review of facility policies.