Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for its residents as required by its own policy. Observations revealed that several resident rooms in the South Wing lacked any personal items or décor, with blank walls and, in one instance, a strong odor of urine and a bedside commode containing urine. Another room was noted to be dark, with no functioning hallway light for at least two days, despite the resident reporting the issue to staff. Staff interviews confirmed awareness of these environmental deficiencies, including the lack of personalization and lighting issues, but indicated that corrective measures had not yet been implemented. Additionally, both the North and South Wings had weight scales in the shower rooms that were visibly rusted, with rust present on the ramps and safety rails, and rust dust observed on the floor. Staff acknowledged that residents could come into contact with the rust and that the equipment should be repaired or replaced. These conditions were observed during multiple site visits and confirmed through staff and resident interviews, demonstrating a failure to maintain a clean and safe environment as outlined in facility policy.