A large-screen TV in the secured unit dining room was playing a loud, violent movie during meals, with screaming, gunfire, crying, and dark scenes visible to residents seated nearby. Two residents with dementia-related cognitive impairment and behavioral issues were directly affected; one became angry and complained the TV was too loud and too dark, while another repeatedly turned off the lights and struck out at an NA when blocked. An LPN, RN, AD, and DON stated the programming was not appropriate for residents with dementia and could increase anxiety or agitation.
A resident who was cognitively intact but repeatedly refused showers and did not change clothing was allowed to share a room and bathroom with other residents. The shared bathroom was repeatedly reported as dirty with stool on the toilet, floor, walls, and bed linens, and staff confirmed the room was odorous and difficult to keep clean. Other residents said they complained about the condition of the bathroom and did not want to share the space with him.
A facility failed to keep resident rooms and hallway areas in good repair and safe condition. A broken window in two residents’ room had an open gap to the outside, and staff confirmed bugs could enter. Two other residents’ rooms had missing drawer fronts, a missing mirror, broken wallboard, peeling paint, and curtains off their hooks. Hallway trim, baseboards, and a resident door corner were also cracked or missing, and staff and the DON stated the conditions were not in good repair.
Unclean Hallway Carpeting and Unrepaired Service Door Gap: The facility failed to maintain a clean, comfortable, and homelike environment when the Golden Oak Hall hallway carpeting remained heavily stained with multiple large dark discolorations after recent shampooing. Staff described the staining as ongoing and related to repeated spills. The facility also left a gap in an exterior service door near the kitchen dumpsters, with daylight visible through the opening; staff acknowledged prior mouse issues, and a family member reported seeing mice in a resident room.
Walk-In Cooler and Kitchen Heat Control Issues: A cook observed the walk-in cooler at 50 F, and the FSD reported the unit had been breaking down repeatedly, with the cooler already too warm when staff arrived after a power outage. The cooler had a missing/broken gasket, a large floor gap covered by a towel, and the reach-in freezer was also off. The kitchen air temperature reached 119 F, causing staff to leave the area intermittently to cool off while maintenance tried to keep equipment functional.
A resident’s room was left cluttered with care items on the floor and on the credenza, including a sling, blankets, heel boots, briefs, wipes, and other supplies, while the resident stated staff did not have time to straighten the room and could not clean it herself. Staff acknowledged the room was routinely left with items on the floor and that there was not enough storage space. The kitchen was also found dirty, with dust, crumbs, smudges, dried drippings, and debris present before food prep, and daily closing checklists showed cleaning duties were completed inconsistently.
A resident room was observed in disrepair with unpainted wall areas, black marks, discoloration, ceiling staining, and scuffed, missing paint on the door frame, and the same conditions remained on follow-up. The memory care dining room floor also had food crumbs and debris under multiple tables; an LPN said it appeared not to have been cleaned after the prior night's meal, and the administrator confirmed the food was still present.
Unsafe and unsanitary resident rooms were observed with clutter, uncovered food, and rodent activity. A resident with schizophrenia and depression had food crumbs and meat under the bed, while another resident reported mouse droppings and hoarded food in a crowded room. Other rooms had overflowing bins, bags of belongings, and uncovered food, and staff reported that some residents refused housekeeping access and that pest control service in resident rooms was inconsistent.
Failure to maintain bedroom ceiling lights for two residents. One resident had impaired cognition, dementia, and was enrolled in hospice, while the other had intact cognition and diagnoses including fibromyalgia, anxiety, depression, and chronic pain. The second resident reported a flickering ceiling light that had not worked for a long time, caused headaches, and left the room dark unless she used the pull-string light. Staff said maintenance requests were supposed to be entered in TELS, but the DON and MT-D confirmed no request had been submitted for the issue.
Failure to maintain building and grounds in good repair: A resident’s room had a damaged closet door jamb, gaps around a window AC unit, and a dirty fan, while other areas of the facility showed rotted and peeling window casings, a hanging piece of exterior trim above the smoking patio, and a hole in the patio sidewalk. The DON described the hanging wood as dangerous and the administrator stated there was no system to track or follow up on environmental concerns and no maintenance staff to monitor or audit these issues.
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