Failure to Maintain Adequate Supplies, Cleanliness, and Pest Control
Penalty
Summary
Facility leadership failed to provide adequate management, resulting in insufficient incontinent and linen supplies, unclean resident environments, and a kitchen infested with vermin. Observations revealed black substances on air conditioner vents, missing wall bases, stained and unmade beds, foul odors, and minimal supplies in utility rooms. Staff interviews confirmed frequent shortages of gloves, wipes, and briefs, with staff resorting to makeshift solutions such as using washcloths or tying pull-ups to fit residents. Residents and staff reported running out of clean linens regularly, and soiled linens with deep stains were observed, some of which could not be cleaned and had to be discarded. Multiple staff and residents reported ongoing pest infestations, including mice, ants, cockroaches, and flies, particularly in the kitchen and resident rooms. The kitchen was described as extremely dirty, with years of accumulated grime, frequent flooding, and evidence of rodent nests and droppings. Staff reported that management was repeatedly informed of these issues, but little to no action was taken. The kitchen also suffered from structural issues such as leaking ceilings and standing water, and cleaning documentation was lacking or unavailable. Housekeeping and maintenance concerns extended to other facility areas, with reports of leaking ceilings, water-stained walls, and mice droppings found on laundry. Staff and residents noted that rooms were not cleaned frequently enough, and pest issues were downplayed by management. Leadership, including the Acting Administrator and Regional Director of Operations, were often unaware of the extent of the problems, citing lack of staff reporting and infrequent presence in affected areas. The facility's failure to maintain a clean, safe, and adequately supplied environment was corroborated by resident council meeting notes and multiple staff and resident interviews.