Failure to Maintain Safe, Clean, and Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations and interviews. Several resident rooms were found with heavily stained carpets, soiled toilets, dirty bathroom floors, torn window blinds, and black substances around window frames and walls. In one instance, a resident's pillow had a dried substance that appeared to be blood, and food debris was scattered throughout the carpet. Residents and staff confirmed that cleaning was inconsistent, with some families resorting to cleaning the bathrooms themselves due to ongoing issues such as toilets not flushing properly and persistent soiling. Additionally, lighting issues were identified, with bathroom lights so dim they were nearly out, as confirmed by the maintenance supervisor. Water temperature logs revealed that hot water in several residents' rooms consistently failed to meet the facility's minimum requirement of 108 degrees Fahrenheit, with recorded temperatures ranging from 77 to 104 degrees Fahrenheit over several months. Residents reported receiving cold showers despite staff efforts to let the water run, and the maintenance director acknowledged delays in obtaining repairs and not implementing immediate interventions when water temperatures were below the required threshold. Medical records reviewed for affected residents indicated significant care needs, including cognitive impairment, dependence on staff for medication administration, assistance with activities of daily living, and various medical diagnoses such as congestive heart failure, pressure ulcers, hemiplegia, and seizure disorders. The facility's own policy states that residents have the right to a clean and safe environment, which was not upheld in these instances.