Unsafe and Uncomfortable Facility Temperatures: An LPN and residents were observed in cold rooms and common areas, with temperatures measured as low as 53 F in the lobby, 57.6 F at the nurses' station, and low 60s in hallways and dining areas. A resident in bed said, "I'm freezing," while the facility acknowledged awareness of the heating issue and had only been closing resident doors to preserve heat. Residents later reported they had complained about being uncomfortable and needing heat for at least two weeks before the survey.
Two residents were affected when the facility failed to maintain a safe and sanitary environment. A resident with a history of falls and limited mobility, who was allowed to self-transfer, used a bathroom grab bar that detached from the wall during a wheelchair-to-toilet transfer, resulting in a fall and later-confirmed rib fractures; facility environmental rounds did not include checking grab bar stability. Another dependent, severely cognitively impaired resident with CHF, prior UTIs, and pressure-ulcer risk was found to have a mattress emitting a strong urine odor beneath clean linens, despite reports from a visitor about urine smells and the absence of any mattress-cleaning schedule in facility checklists.
Unclean and Poorly Maintained Shower Room: The second floor Ledgewood 2 shower room had chipped and cracked ceiling paint, a black/brown substance on the floors and walls, and a used wet washcloth on the shower floor. An LPN stated environmental rounds were done every other week and that the shower was not clean, and the Maintenance Director also confirmed the room was not clean. Environmental Rounds logs did not identify concerns for any of the 6 showers over the past 6 months.
Resident areas on the C/D and E/F units were found with rust-stained drop ceiling frames, damaged wallpaper, bowed or broken ceiling tiles, loose cove base molding with debris or black growth behind it, missing thresholds, and chipped flooring tiles. Facility interviews showed the QAPI plan addressed only Units A and B, and leadership reported no written plan or timeline for repairs on the other units; maintenance relied on requests and limited rounds rather than a building-wide audit.
Resident rooms were not maintained within the required 71 to 81 degree range. A resident with dementia, psychotic disturbance, mood disturbance, and anxiety reported the room was cold most days and needed extra layers and blankets to stay comfortable. Survey observations found room temperatures in the mid-to-high 60s at resident level, while a thermometer placed near the ceiling read 71 degrees, and the baseboard heater was cold. The DON/maintenance staff acknowledged temperature discrepancies, noted temperatures were only documented when below 70 degrees, and observed multiple rooms on the wing below range with residents using extra blankets and layered clothing.
A resident with dementia and a known elopement risk was found outside exterior fire doors after a fire alarm event in which a bathroom fan caught fire and activated the facility’s alarm system. Later observation showed that one of the exterior fire doors, controlled by a keypad and magnetic lock, did not latch shut on its own and had to be pulled closed, with interior weather stripping noted on the bottom of the door. The Maintenance Director reported that fire alarms disable door alarms and cause the doors to open automatically, acknowledged that the doors were old and known to require pulling to close, and stated that maintenance did not check the doors after the alarm to ensure they were secured. The DNS also confirmed that the exterior fire doors were not checked for secure closure following the fire event.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failure to ensure treatment and supports for daily living were delivered safely.
Multiple resident rooms were observed to have temperatures above 81°F, and several residents reported ongoing discomfort due to excessive heat over a period of weeks. Requests for portable air conditioners were not fulfilled in a timely manner, and the facility was unable to provide temperature logs for several days during a period of high outdoor temperatures. The Maintenance Director confirmed ongoing issues with the air conditioning system.
Multiple observations revealed persistent issues with cleanliness and maintenance, including soiled floors, peeling paint, leaking sinks, broken tiles, and non-functioning lights across several units. Residents expressed dissatisfaction with the facility's condition and lack of completed repairs. Staff interviews highlighted inadequate training, missing maintenance records, and housekeeping staffing shortages, with supervisors unable to confirm recent cleaning. The facility could not provide a maintenance policy when requested.
The facility failed to maintain laundry equipment and ensure an adequate supply of linens, resulting in residents experiencing delays in receiving clean personal laundry and a shortage of washcloths and towels for care. Staff and residents reported ongoing issues with laundry turnaround and linen availability, with only one washing machine functioning for months and some equipment out of order for years. Despite repeated reports to administration, the facility did not take effective action to address the shortages or utilize alternative solutions.
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