Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility's Licensed Nursing Home Administrator (LNHA) failed to ensure the implementation of the facility's Quality of Life - Homelike Environment policy and procedures, resulting in a failure to provide a safe, clean, comfortable, and homelike environment for residents. During a survey, multiple deficiencies were observed across all three nursing units, including resident rooms with peeling wallpaper and paint, broken or damaged furniture, soiled and stained floors, stained toilet bowls, grab bars coming off the walls, holes in walls, missing trim, and discolored ceiling tiles. In addition, shower rooms were found with rusted fixtures, damaged shower curtains, broken soap holders, and missing grout. These conditions were confirmed by both staff and residents, with some residents reporting that issues such as broken furniture and soiled areas had persisted for extended periods without resolution. Staff interviews revealed a lack of consistent reporting and follow-up on maintenance issues. While some staff were aware of the process for submitting maintenance requests through a computerized work order system, not all concerns identified by the surveyor were present in the system. Housekeeping and maintenance staff stated that cleaning and maintenance tasks were performed regularly, but acknowledged that certain issues, such as rust stains in toilets and soiled air conditioning units, had not been adequately addressed. The Environmental Service Director and other staff confirmed the presence of these deficiencies during the surveyor's walkthroughs. The LNHA and other facility leadership acknowledged awareness of the environmental issues and confirmed that many of the problems identified by the surveyor were known to them. Despite previous citations for similar deficiencies and a plan of correction that included regular audits and cleaning protocols, the survey found that many of the same issues persisted. Documentation provided by the facility, such as a quote and a check for new furniture, did not demonstrate that corrective actions had been completed, and there was no evidence that the necessary repairs or replacements had been made at the time of the survey.