The facility failed to maintain a clean and homelike environment when a cognitively intact resident with anxiety reported that their room had not been cleaned for several days, and surveyors observed dirty floors, debris, dark stains in the toilet bowl, and a urine odor in the bathroom. The shared bathroom and multiple shower rooms were also found with dark substances on toilet surfaces, unclean baseboards, and unkept conditions. Only one housekeeping staff member, the Director of Housekeeping, was working at the time of the survey, and leadership acknowledged an expectation that resident areas be clean.
The facility did not ensure a safe, clean, and homelike environment in a first-floor shower room. Surveyors observed broken floor tiles with missing pieces, with several holes containing black sludge-like material and standing water, and another hole filled with gravel and rocks. They also noted multiple holes in the shower wall near the soap dispenser and black discoloration on the caulking, including a larger discolored area in one corner of the shower and other random areas of caulking with similar black coloring. These environmental issues were present in a shower area used by residents and were acknowledged by facility leadership during the survey.
Two residents experienced deficiencies in their environment: one had personal belongings go missing after admission, with multiple staff failing to recover or replace the items, and another suffered significant sleep loss due to a neighbor's loud television, despite repeated complaints to staff. Staff interviews revealed a lack of training and ineffective interventions, resulting in unresolved issues with both property loss and excessive noise.
Surveyors found widespread environmental deficiencies, including dirty and dusty fixtures, vents, and fans in common areas, as well as unkept and unsanitary shower rooms with mold-like substances, rust, and damaged fixtures. A resident with pneumonia expressed concerns about the shower room's cleanliness and safety, and another resident was bothered by scratches and missing paint in their room. Facility staff acknowledged these issues during the survey.
Surveyors found that the facility did not provide a homelike environment in two of three hallways reviewed. A resident's personal fan was observed with a thick layer of dust and grime, and the resident reported waiting for staff to clean it. Multiple rooms had walls with scrapes, holes, and uncleanable surfaces, as well as dust build-up, sticky furniture, and other cleanliness issues. Residents and staff confirmed the need for cleaning and repairs.
A resident with anxiety and reduced mobility reported missing six packs of cigarettes from a locked storage box at the nurses' station. Facility policy required smoking materials to be stored in these boxes, but it was found that the keys could open multiple boxes and the drawer was not consistently locked. Staff confirmed the security issues, and the facility lacked adequate tracking and safeguarding of residents' property, resulting in the loss.
A resident with asthma and congestive heart failure was found to have a large section of missing sheet rock and debris behind their bed, resulting from the bed hitting the wall. The damage, which had been present for several months, was not repaired despite staff and maintenance being aware of the issue. The Administrator confirmed the repair was not completed in a timely manner.
Multiple deficiencies were observed in the facility's physical environment, including a resident room wall in disrepair, buckled carpet creating tripping hazards in a high-traffic area, and a resident's window that was unsecured and lacked a screen. The Maintenance Director was unaware of some issues and confirmed there was no system in place to routinely check or repair windows for safety.
A resident with borderline personality disorder was unable to independently operate their bedside light due to a shortened chain, leading to frustration and repeated requests for staff assistance. Staff had inconsistent knowledge about the resident's ability to use the light, and the care plan did not address the modification. The chain had been shortened for safety, but key staff were unaware this prevented the resident from using the light without help.
Two residents experienced deficiencies in environmental cleanliness and room repair, including a bathroom with dried feces, an electric outlet with exposed wires, and a window with missing trim and jagged edges. Housekeeping and maintenance staff were aware of these issues, and residents and family members reported ongoing concerns about cleanliness and safety.
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