Failure to Maintain Clean, Homelike Environment and Adequate Resident Care Supplies
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of unsanitary and unsafe conditions throughout the building. Surveyors noted the presence of black substances resembling mold and dirt in air conditioning vents, musty odors, missing wall bases, stained and soiled mattresses and linens, and evidence of water damage such as caved-in ceilings and water-stained walls. The North and South Halls, shower rooms, laundry, and basement areas all exhibited significant cleanliness and maintenance issues, including cracked tiles, biofilm in drains, missing non-skid strips, and the presence of mouse droppings and flies. Residents and staff reported persistent odors of urine and infrequent cleaning of rooms and equipment, with some residents lying in soiled beds and reporting that their rooms were not cleaned regularly. The facility also failed to maintain adequate supplies of personal care items and linens. Observations revealed repeated shortages of appropriately sized briefs, gloves, cleansing wipes, and linens in both the North and South Hall supply rooms, as well as the central supply area. Staff interviews confirmed that shortages were frequent, with staff sometimes resorting to makeshift solutions such as stapling briefs together or using washcloths in place of wipes. Staff reported that supplies often ran out before new shipments arrived, and that communication about supply needs did not always result in timely restocking. Residents corroborated these accounts, stating that they were sometimes left in soiled conditions due to lack of supplies, and that the facility often ran short on briefs and other essentials, especially toward the end of the week. Interviews with staff and residents further highlighted the impact of these deficiencies. Residents described being dressed in wet beds, smelling of urine, and seeing mice in their rooms. Staff reported confusion over responsibilities for cleaning mattresses and equipment, and housekeeping staff indicated that they did not clean mattresses or strip linens. The facility's policies required a clean, sanitary, and homelike environment, but observations and interviews demonstrated that these standards were not being met. The lack of adequate supplies and poor environmental maintenance directly contributed to the failure to honor residents' rights to a safe and comfortable living environment.