Failure to Maintain Sanitary and Comfortable Environment in Secured Unit
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment in the secured unit, as evidenced by multiple observations, interviews, and record reviews. Staff did not ensure that showers and tubs were cleaned between residents, resulting in the presence of slimy, black mold-like substances, dirty floors, and hair left in bathing areas. Residents reported that showers were not cleaned after each use, with some stating they had to place towels on the floor due to the slimy conditions and that they often encountered other residents' hair and soap scum. Housekeeping and nursing staff interviews confirmed uncertainty about cleaning responsibilities and schedules, and cleaning supplies were not readily accessible to all staff responsible for cleaning between residents. The physical environment was further compromised by unrepaired ceiling damage in the shower area, including peeling sheetrock, missing plaster, water stains, and rusted fixtures. The damage was attributed to a roofing incident, and the ceiling remained in disrepair due to unresolved disputes between the facility and the roofing company. Observations documented large, dark water spots, missing ceiling tape, and exposed foam in furniture, all of which contributed to an environment that was not clean or well-maintained. Additionally, the facility did not maintain an effective pest control system, as evidenced by ongoing rodent activity reported by multiple residents and staff. Residents described seeing mice in their rooms and throughout the secured unit, with mouse droppings found in sinks and on floors. Pest control records indicated an escalation in rodent activity, with increased bait stations and glue traps, but the problem persisted. These deficiencies affected at least three residents with cognitive and psychiatric diagnoses, who expressed feelings of unsafety and distress related to the unsanitary and uncomfortable environment.