Failure to Maintain Sanitary and Functional Resident Bathrooms
Penalty
Summary
The facility failed to maintain a safe, sanitary, and functioning environment for residents, as evidenced by multiple rooms with sinks that were either clogged or filled with discolored standing water. Observations revealed that in several resident rooms, sinks did not drain after running water for two minutes, and in some cases, the water in the sinks was brown or gray with visible sediment. Toilets in these rooms also contained discolored water and, in one instance, an adult incontinent brief was found in the toilet. These issues persisted for several days, impacting nine residents, some of whom reported the problems to staff without resolution. Residents affected by these deficiencies included individuals with significant mental health diagnoses such as schizoaffective disorder, bipolar type, agoraphobia with panic disorder, and post-traumatic stress disorder. At least one resident was cognitively intact and reported the issue to staff, while another, who was moderately cognitively impaired, stated that the sink had been clogged for two or three days and that staff had attempted to use a plunger to resolve the issue. Staff interviews confirmed that clogged sinks and toilets were a recurring problem, with residents reportedly placing items such as ramen noodles, tea bags, toilet paper, and sanitary pads in the plumbing, contributing to the blockages. The facility's maintenance and communication systems were found to be inadequate in addressing these ongoing environmental concerns. The Maintenance Director reported being the only maintenance staff member and stated that a new system for reporting maintenance needs had not yet been implemented. Staff were unclear about the process for reporting maintenance issues, with some relying on communication books at nurse stations and others reporting verbally to nurses or administration. The Department Manager and DON acknowledged that the clogged sinks and toilets had been a persistent issue, and that maintenance was not always promptly notified or able to resolve the problems in a timely manner.