Failure to Maintain Safe, Clean, and Well-Maintained Interior and Exterior Areas
Penalty
Summary
Facility staff failed to maintain a safe, clean, and comfortable physical environment in multiple interior areas. During complaint survey observations, damaged drywall was noted on two walls in the nourishment room, along with a cabinet door that flung open due to a broken bottom hinge and a sink cabinet with water damage and a hole in its base. In a shower room on Sudbrook, an electrical box contained two red and two black uncapped wires hanging out. In the Sudbrook supply room, a package of clear cups, a blue basket, and plumbing tools and parts were stored on a blanket under the sink. A broken soap dispenser was observed in another shower room, with the front cover placed on a shower bed inside the stall. Staff interviews revealed that although there were maintenance binders on each unit and a process to report issues during morning meetings, the identified concerns had not been documented in the binder, and no one had inspected the cabinet prior to the surveyor. The DON and LPN unit manager described reliance on unit maintenance books and verbal reporting, while the Maintenance Director reported that nourishment and supply rooms were not part of regular preventive checks, the maintenance book was not always checked daily, and there was no checklist to verify completion of repairs. Additionally, three dining room windows on Mount [NAME] had large gaps at the upper and lower sections, allowing cold air to enter the room until the surveyor demonstrated the issue to the Maintenance Director. The exterior environment was also not maintained in a clean and orderly condition. On two consecutive mornings, surveyors observed discarded face masks, gloves, water bottles, plastic cups, straws, plastic bags, paper, and other debris scattered throughout the parking lot, along the curb, in a tree line, and near the front of the building. Debris was noted in trees and bushes, lined against the building, and around the porch area at the entry door, where a trash can had debris nearby and a broken orange snow shovel and black plastic piece were present, with additional plastic bags and paper in the adjacent grass. During interviews, the EVS Director stated that housekeeping was responsible for cleaning the parking lot and that a porter was assigned daily to this task, and also stated that she personally monitored whether it was done, but acknowledged she had not checked the area since a recent snow event.
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