Failure to Maintain Clean, Comfortable, and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for five residents reviewed for environmental conditions. Multiple residents reported frequent issues with the availability of bed linens and bed pads, sometimes waiting until late in the day or being unable to rest due to the lack of clean linens. Staff interviews confirmed that shortages of linens, bed pads, and wash cloths were common, especially when the facility's dryer was not functioning, leading to the use of towels, bath blankets, or even cut-up towels as substitutes for proper bedding and hygiene supplies. Physical observations revealed significant environmental deficiencies in resident rooms, including large holes in the walls above air conditioning units that were covered with duct tape. These holes were present in at least two rooms, and residents stated that the damage existed prior to their occupancy. The Maintenance Director measured the holes, confirming their size, and acknowledged a backlog of maintenance requests. Staff also reported that termites were present in certain areas, and that the wall damage was extensive enough for a hand to go through in one instance. Residents affected by these deficiencies had various medical conditions, including hemiplegia, cognitive impairment, depression, and incontinence. Some residents with intact cognition expressed discomfort and dissatisfaction with the lack of proper linens and the use of makeshift substitutes, particularly when dealing with incontinence. Facility policies reviewed emphasized the responsibility of department directors to report maintenance needs and the importance of resident dignity, but these were not consistently upheld in practice.