Failure to Maintain Safe, Clean, and Comfortable Environment
Penalty
Summary
Multiple residents experienced discomfort due to inadequate temperature regulation within the facility. Several residents, including those with cognitive impairments and chronic medical conditions such as Parkinson's disease, heart failure, dementia, and diabetes, reported feeling cold over several days. Observations confirmed that room temperatures were as low as 65 degrees, and residents were seen using extra blankets and clothing to keep warm. Despite complaints, the heating system was not turned back on, as the maintenance director stated that corporate instructions were to leave it off in anticipation of warmer weather. Some residents did not receive additional blankets when distributed, and staff and leadership did not express concerns when interviewed about these issues. Sanitation and cleanliness were also found to be deficient throughout the facility. Observations included the presence of roaches on medication carts, in resident rooms, and in shower areas. There were also reports and direct observations of foul odors, particularly urine and feces, in hallways and shower rooms. Shower rooms were found to be dirty, with stained curtains, unflushed toilets, and soiled linens left on the floor. Housekeeping staff acknowledged challenges in maintaining cleanliness due to ongoing resident care and a lack of replacement supplies, such as clean shower curtains. Facility documentation and interviews confirmed persistent pest control issues, with pest infestations even affecting kitchen equipment such as the dishwasher. Environmental maintenance was lacking, as evidenced by damaged walls with deep scratches and unpainted patches, missing or jagged floor tiles, and the presence of debris and dead pests in resident rooms. Some rooms lacked homelike decorations and had strong odors. Maintenance records revealed ongoing problems with the heating and cooling systems, including a nonfunctional chiller and leaking air conditioning units. Work orders and internal communications documented delays in repairs and unresolved issues with essential equipment, such as the dishwasher and oven, further contributing to an environment that was not clean, safe, or comfortable for residents.