Surveyors identified multiple failures to maintain a safe, clean, and homelike environment, including damaged and warped flooring, a wall vent held in place with peeling tape, and stained carpet with food debris in several rooms. On another unit, a resident reported seeing a mouse in their room, where a full trash can, debris on the floor, and chipping along the wall baseboard were observed. In a separate room, a large pile of laundry was found stacked on the floor without an appropriate container for storage.
Staff failed to maintain a homelike environment when a water-stained ceiling tile and damaged drywall behind a bed in two resident rooms were not identified or reported. While the Maintenance Director stated that weekly and monthly audits are conducted and that staff are expected to submit work orders through TELS, no work orders were received for these issues. The DON did not believe any work orders had been submitted, a GNA reported not noticing the damaged drywall, and an RN acknowledged not paying attention to maintenance concerns during rounds, allowing the environmental damage to remain unaddressed in the residents’ rooms.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
A resident's right to a safe, comfortable, and homelike environment was not upheld when the facility failed to inventory and safeguard the resident's personal belongings. During a complaint investigation, staff were unable to account for multiple missing items, including clothing and a phone charger, and review of both electronic and paper records showed that no personal belongings inventory had been completed or maintained for the resident, contrary to facility policy requiring such documentation at admission and updates as new items are brought in.
Staff failed to maintain a clean, sanitary, and orderly room for a resident, resulting in persistent fruit flies, dirty surfaces, and unresolved maintenance issues. A complaint about fruit flies led to observations of multiple food trays with leftover food left in the room, visibly dirty bedside tables and dresser drawers, debris on the floor, and peanut butter jars with residue on the outside. On a subsequent visit, numerous fruit flies were counted in the bathroom and on walls and the sink, large cobwebs were present around closet doors, and the room still had dirty drawers and uncontained peanut butter jars. Additional issues included a constantly running toilet, an unused open-ended pipe near the toilet, cracked drywall around the sink, and old drill holes under the television, all confirmed by the DON.
Physical Environment Not Maintained on Station 2: Several resident rooms on station 2 had marred doors, doorframes, and walls, along with loose or missing tile around sinks, a warped sink counter, a drawer out of alignment, and a bathroom door with holes and peeling paint. The Maintenance Director acknowledged the disrepair and said repairs depended on budget, and the LNHA was later notified of the concerns.
Staff failed to maintain a sanitary, safe, and comfortable environment, particularly on one unit, where a resident was found in bed without clothes, lying on stained linens with a soiled sheet covered in gnats placed on a trashcan, and in a room cluttered with discarded incontinence products and clothing on the floor. Multiple rooms and common areas had stained and cracked ceiling tiles, missing or damaged flooring and laminate surfaces, non-functioning or uncovered lights, rusted exhaust fans, peeling drywall, and dirty, sticky, or discolored floors. One room’s wall A/C unit had visible gaps to the outside, with cold air entering, accumulated dust, cobwebs, and a loose electrical box, while several beds on the unit had no linen. A staff member reported there was no linen available overnight or in the morning, and the maintenance director acknowledged ongoing linen shortages and inoperable laundry equipment, as well as unaddressed structural and cleanliness issues inside and outside the building.
Unsanitary Resident Room and Bathroom Conditions: A resident’s room and bathroom had a strong urine odor, a sticky bathroom floor with dark brown residue, brown-stained floor tiles, and a toilet bowl heavily stained with bowel movements. A RN said the odor had been present most of the time, and the interim NHA and housekeeping manager confirmed the conditions and noted the room was next for deep cleaning and stripping.
A resident's room was observed with a grey bed pan under the sink in the bathroom and a used blue surgical mask on the floor in the corner. The UM/RN acknowledged the items on the floor were an issue and called housekeeping to remove them.
Unsanitary Storage of Toilet Plunger in Resident Bathroom: A surveyor observed a toilet plunger stored in a plastic bag next to the toilet in a resident bathroom, with a brown liquid substance coating the bottom of the bag. The Maintenance Director confirmed that plungers should not be kept in soiled plastic bags in residents' bathrooms.
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