Failure to Address Bug Infestation, Staffing Shortages, and Unsafe Conditions
Penalty
Summary
The Administrator failed to manage the facility in a manner that ensured effective use of resources and quality of life for residents, as evidenced by ongoing issues with bug infestation, inadequate direct care staffing, and unsafe living conditions. Multiple confidential interviews with staff and residents revealed that the Administrator was not present on the floor, did not engage with staff or residents, and was perceived as indifferent to the facility's challenges. Staff morale was reported to be low, and concerns about vacancies and pest infestations were largely ignored by the Administrator. One resident reported sustaining a cut on his arm from a damaged bathroom door frame, which had not been repaired for over a month due to the absence of a Maintenance Director. The Administrator acknowledged the delay in repairs and indicated that the new Maintenance Director would address the issue when possible. The same resident described severe gnat infestations in his room and the dining area, with gnats contaminating food and beverages. Staff and residents reported that the gnat problem persisted for several weeks, and staff requests to use pest control devices were denied by the Administrator. Another resident reported developing maggots between her toes, which she attributed to the insect infestation in her room. The facility also experienced significant staffing shortages, particularly in housekeeping and laundry. The Administrator had terminated the Housekeeping Manager, leaving only one full-time housekeeper/laundry staff member, and CNAs were required to cover laundry duties, leading to frequent shortages of linens, especially during night shifts. The Administrator admitted to not seeking additional support or outside services to address the laundry staffing gap and had not communicated with staff or residents about the impact of these shortages. The Administrator was aware of the gnat issue but did not fully grasp its extent and did not escalate the problem to higher management or seek alternative pest control solutions.