Failure to Maintain Clean, Safe Environment and Timely Communication
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for multiple residents on the third floor nursing unit, as evidenced by direct observations, interviews, and record reviews. In one resident's room, there was a persistent puddle of water on the floor due to a leaking ceiling and a disconnected sink drain, which had been ongoing for two to three months. The sink and counter were partially pulled away from the wall, and both the soap and paper towel dispensers were missing, with visible wall damage where they had been ripped off. The room also lacked a cover for the light bulbs above the sink and the thermostat, and the bathroom door would not stay closed, requiring a trash can to keep it shut. These issues were confirmed by housekeeping staff, the DON, and the maintenance supervisor, who indicated that some of the problems had not been reported or addressed in a timely manner. Additional observations on the same unit revealed widespread stained ceiling tiles in several residents' rooms and a broken light cover in another room. In one resident's room, the shared bathroom was found to be dirty, with urine stains and a strong odor, which was confirmed by both the resident and an LPN. The facility's housekeeping policy required rooms and bathrooms to be clean, free of odors, and for dispensers to be checked and replaced as needed, but these standards were not met in the observed areas. The facility also failed to ensure that phone calls were answered in a timely manner, which had the potential to affect all residents. There were documented instances where phone calls to the facility went unanswered for extended periods, including one call that rang 28 times without being answered and another that rang 18 times before being picked up. Staff interviews revealed that there was no receptionist on night shift, and nursing staff were sometimes too busy to answer the phone, despite the expectation that calls should be answered within three rings. This issue was further highlighted by a fire department incident report noting a delay in entering the building due to no one being at the front desk.