Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Facility staff failed to ensure a safe, clean, comfortable, and homelike environment for all residents, as evidenced by multiple observations and interviews. Surveyors noted a strong urine odor in the hallway past the lobby on two separate occasions, and flies were observed throughout the facility, including resident rooms and hallways over several days. Breakfast trays were served with plastic utensils due to staff callouts, and a damaged breakfast tray with sharp corners was delivered to a resident before being removed. Wall-mounted hand sanitizer units were found to be missing or loose, and there were missing tiles in hallways and resident rooms, as well as a baseboard pulled away from the wall with a blackish gray residue. Mattresses in one room were heavily stained and had a crackled appearance. A resident with multiple chronic conditions, including hypertension, heart failure, and chronic kidney disease, was observed eating breakfast after his tray with sharp corners was removed due to safety concerns. Staff interviews confirmed that damaged trays should be reported and replaced, but the Dietary Manager was not aware of any damaged trays prior to the surveyor's inquiry. Another resident, also with significant medical history, experienced a persistent leaking sink in her room, with a bath basin repeatedly observed full of water under the sink over several days. The resident reported that the issue had not been resolved despite staff emptying the basin. Additionally, a footboard was observed leaning against the wall in a resident room, with the corresponding bed missing its footboard. The resident, who has moderate cognitive impairment and multiple diagnoses, stated the footboard belonged to his roommate, but could not recall how long it had been there. These findings were reviewed with facility leadership during the survey, and no further information was provided at that time.