Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Facility staff failed to provide a safe, clean, comfortable, and homelike environment for residents, as evidenced by multiple deficiencies observed during the survey. Residents consistently did not receive knives with their meals, and when knives were provided, they were plastic and inadequate for cutting certain foods such as pork chops. Resident Council minutes over several months documented repeated complaints about the lack of proper utensils, with residents expressing frustration and reporting that they had to ask families to bring in knives or resort to eating with their fingers. Staff interviews confirmed a shortage of knives in the kitchen, and although a purchase order for new silverware was provided, the issue persisted at the time of the survey. The facility also failed to maintain clean and functional bathing areas. Residents reported missing tiles and an inoperative whirlpool tub in two of the four bathing areas. Observations confirmed missing and chipped tiles, as well as a whirlpool tub with non-functional jets and a leaking door. Staff acknowledged the ongoing issues, with maintenance efforts hampered by difficulties in sourcing replacement parts and uncertainty about whether the whirlpool would be replaced. The administrator was aware of the problems but could not confirm plans for a replacement tub for residents who preferred baths. Additional deficiencies included unclean resident equipment and nutrition areas. One resident's wheelchair was repeatedly observed to be soiled with a dry, tan-colored substance over several days, despite staff being responsible for cleaning and a cleaning schedule being in place. Another resident's toilet and bedside commode were found with brown matter smeared on them over multiple days, contrary to the facility's policy of daily cleaning. Furthermore, white trays placed beneath ice machines in nutrition rooms were found to contain debris such as food waste, wrappers, and other contaminants, with staff confirming these trays were not part of the manufacturer's setup and should be monitored daily for cleanliness.