Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, comfortable, and homelike environment for multiple residents. During facility tours on several dates, a strong odor of urine was present throughout multiple hallways, persisting over several days. Interviews with a resident's family member revealed that the resident was found dirty, soaking wet, and in unsanitary conditions, with hospice aides also reporting the resident being found in a mess. The family member attributed the persistent urine odor to staff leaving soiled linens at the foot of beds for extended periods before removal. Another resident reported a cockroach infestation in her room, confirmed by direct observation of glue pads containing multiple roaches and live roaches present. The Maintenance Director acknowledged ongoing pest control efforts but admitted they had not been effective, as evidenced by pest sighting logs documenting numerous recent roach sightings in various halls. Additionally, an observation of a specific room revealed a visibly soiled privacy curtain, dirty pillows without pillowcases, and a resident who reported not receiving linen changes or housekeeping services for a week despite repeated requests. The Housekeeping Director confirmed that the cleaning schedule for the month was not yet posted and described the general cleaning procedures, but did not address the lack of regular cleaning in the affected room. These findings demonstrate a failure to provide a clean and comfortable environment for residents, as required.