Failure to Maintain Safe, Functional, and Sanitary Resident Environment
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in 15 of 18 rooms reviewed for physical environment. Observations revealed multiple deficiencies, including non-functioning toilets, missing toilet seats, lack of hot or cold water at sinks, dim or burnt-out bathroom lighting, leaking toilet tanks, and unsafe or broken electrical outlet covers. In several instances, air conditioner plugs and cords were found with scorch marks or were identified as fire hazards. These issues were present in both occupied and unoccupied rooms, and some residents reported having to use hand sanitizer instead of washing hands due to lack of hot water, or being unable to use the bathroom facilities as intended. Interviews with residents and their family members indicated that maintenance issues were not being addressed in a timely manner, and there was a lack of communication regarding the status of repairs. One family member described moving a resident through multiple rooms, each with significant environmental deficiencies, before ultimately transferring the resident to another facility within 24 hours. Residents reported ongoing maintenance problems, delays in repairs, and a lack of feedback from staff or maintenance about when issues would be resolved. Some residents had adapted to the deficiencies, such as turning water valves on and off themselves or avoiding the use of certain facilities. Staff interviews revealed confusion and inconsistency in the process for reporting maintenance issues. Although the facility had recently transitioned from paper maintenance request forms to a digital system (TELS), most staff continued to use the paper system, and many were unaware of the environmental issues present in the facility. The Maintenance Director stated he was only aware of issues that were reported to him and that he could not address unreported problems. The Director of Nursing and Administrator both acknowledged the importance of a safe and functional environment but noted that staff were not consistently using the new reporting system, and there was no policy provided that addressed maintaining a safe, comfortable, homelike environment.