Failure to Maintain Clean Environment and Person-Centered Dining
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment on one of its nursing units, as evidenced by multiple observations and resident interviews. One resident reported a water leak in the bedroom from the unit above, resulting in water pouring from the ceiling, and subsequent observations confirmed water-damaged and discolored ceiling tiles in both the bedroom and bathroom. Additionally, a wall panel in another room was observed to be peeling off. These environmental deficiencies were directly observed and reported by residents. The facility also failed to provide a person-centered dining experience as outlined in its own policies. One resident who returned late from dialysis reported that lunch trays were left at the bedside and were cold upon return, with staff stating they were not allowed to reheat the food. Staff interviews revealed inconsistent practices regarding reheating food, with some indicating that trays could be sent back to the kitchen for reheating, while others stated that microwaves on the unit were primarily for employee use. Furthermore, during a dining observation, residents were served lunch significantly late and were provided only plastic silverware, with no explanation given for this deviation from policy. These actions and inactions resulted in a failure to meet the residents' rights to a safe, clean, and homelike environment and to receive appropriate support during daily living activities, including dining.