Failure to Maintain Sanitary and Homelike Environment; Inadequate Bathing Facilities
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents. Upon entering the facility, there were strong urine and bowel odors present in the hallways, and several resident room floors were observed to have dark debris and dirt. The hallway walls had chipped paint, missing paint patches, and exposed areas where dispensers had been removed. A sharp nail was found protruding from the wall near a handrail, creating a safety hazard. Additionally, soap dispensers in some resident rooms were nonfunctional, and the floors in certain rooms were covered with thick debris. Equipment such as apex machines, used to assist residents with standing, were found dirty and covered with duct tape, which staff acknowledged made cleaning difficult and could harbor germs. The dumbwaiter, used for both soiled laundry and meal carts, was observed to be dirty with chipped paint and debris, and cleaning logs indicated infrequent cleaning. Staff interviews confirmed that cleaning protocols were not consistently followed, and the cleaning schedule for the dumbwaiter had only recently been posted. The facility's only shower room, serving all residents, was out of service for an extended period due to the discovery of a deteriorated subfloor during attempted repairs. The shower room had been unavailable since the end of October, and the renovation process was delayed due to the need for contractor availability and the extent of the required repairs. During this time, residents were provided with bed baths and a portable shower sink as alternatives. The facility communicated the shower room closure to residents and families but did not notify the Department of Health about the loss of shower access. Interviews with facility leadership confirmed the timeline of the shower room's closure and the ongoing renovation process, as well as the lack of notification to regulatory authorities. Throughout the investigation, staff acknowledged ongoing issues with cleanliness, maintenance, and equipment sanitation. The Director of Environmental Services reported persistent complaints about dirty floors and acknowledged that some tiles trapped dirt due to old wax and needed replacement. Both the Infection Preventionist and the DON confirmed that the apex machines were dirty and that duct tape should not be used on equipment. The DON also stated that the facility's patchwork and missing paint did not contribute to a homelike environment. These findings collectively demonstrate the facility's failure to provide necessary housekeeping and maintenance services to ensure a sanitary, orderly, and comfortable environment for residents.