Resident Falls Due to Nonfunctional Bathroom
Summary
The facility failed to provide a functioning toilet for a resident, leading to a potential fall incident. The resident, who was admitted with dementia, muscle weakness, and mobility issues, had a bathroom that was out of order. The resident's Annual Minimum Data Set (MDS) assessment indicated occasional bladder incontinence and a moderately impaired mental status. On the day of the incident, the resident attempted to find an alternate bathroom due to the nonfunctional toilet in her room, which resulted in a fall in the hallway. The Certified Nursing Assistant (CNA) observed the resident walking in the hall without a walker and expressed the need for a bathroom. The CNA confirmed the bathroom was out of order and noted the absence of a bedside commode. While the CNA was looking for an alternate bathroom, the resident fell. The Maintenance Supervisor later confirmed the bathroom issue was not logged, and the Director of Nursing stated that a bedside commode should have been provided, and staff should have been more attentive to the resident's needs.
Penalty
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Multiple resident rooms experienced ongoing issues with clogged sinks and discolored standing water, with some sinks and toilets remaining unusable for several days. Affected residents, including those with mental health conditions, reported the problems to staff, but maintenance response was delayed due to inadequate communication and staffing. Staff interviews confirmed that improper items were being placed in sinks and toilets, and that the facility's system for reporting and addressing maintenance concerns was ineffective.
Two residents who required wheelchairs were unable to access the bathrooms in their rooms due to doorways that were narrower than their wheelchairs. One resident had to maneuver awkwardly to use the bathroom and often waited for a shared accessible bathroom, while another sustained a minor injury and was unable to use the toilet or sink, instead using a container to empty a urinary catheter. Staff confirmed that most wheelchairs could not fit through the bathroom doors on certain units.
A resident was temporarily housed in a storage area within the secure memory care unit that lacked a sink and toilet, due to all regular rooms being occupied. Staff monitored the resident and assisted with toileting by escorting the individual to a shower room elsewhere in the unit. The area was confirmed to have no bathroom facilities during this time.
The facility failed to maintain functional bathing facilities, leaving residents without access to showers for up to two weeks. One shower room had been non-functional for eight months, and the other was out of order for two weeks, with no system in place for maintenance work orders.
Failure to Maintain Sanitary and Functional Resident Bathrooms
Penalty
Summary
The facility failed to maintain a safe, sanitary, and functioning environment for residents, as evidenced by multiple rooms with sinks that were either clogged or filled with discolored standing water. Observations revealed that in several resident rooms, sinks did not drain after running water for two minutes, and in some cases, the water in the sinks was brown or gray with visible sediment. Toilets in these rooms also contained discolored water and, in one instance, an adult incontinent brief was found in the toilet. These issues persisted for several days, impacting nine residents, some of whom reported the problems to staff without resolution. Residents affected by these deficiencies included individuals with significant mental health diagnoses such as schizoaffective disorder, bipolar type, agoraphobia with panic disorder, and post-traumatic stress disorder. At least one resident was cognitively intact and reported the issue to staff, while another, who was moderately cognitively impaired, stated that the sink had been clogged for two or three days and that staff had attempted to use a plunger to resolve the issue. Staff interviews confirmed that clogged sinks and toilets were a recurring problem, with residents reportedly placing items such as ramen noodles, tea bags, toilet paper, and sanitary pads in the plumbing, contributing to the blockages. The facility's maintenance and communication systems were found to be inadequate in addressing these ongoing environmental concerns. The Maintenance Director reported being the only maintenance staff member and stated that a new system for reporting maintenance needs had not yet been implemented. Staff were unclear about the process for reporting maintenance issues, with some relying on communication books at nurse stations and others reporting verbally to nurses or administration. The Department Manager and DON acknowledged that the clogged sinks and toilets had been a persistent issue, and that maintenance was not always promptly notified or able to resolve the problems in a timely manner.
Inaccessible Bathroom Facilities for Wheelchair Users
Penalty
Summary
The facility failed to ensure that residents who required the use of a wheelchair for mobility had access to a bathroom in or near their rooms that could be quickly and safely accessed. For two residents, the bathroom doorways in their rooms were narrower than the width of their wheelchairs, preventing direct entry. One resident, who was cognitively intact and required moderate assistance for transfers, had to position their wheelchair at an angle in the doorway and pull themselves up using a grab bar inside the bathroom, while staff stood outside the bathroom and out of reach. This resident reported difficulty accessing the bathroom and often had to wait to use a more accessible bathroom in the hallway, which was frequently occupied. Another resident, who had moderate cognitive impairment, neuropathic bladder, a colostomy, and chronic kidney disease, was unable to fit their wheelchair through the bathroom door and sustained a minor injury when attempting to enter. This resident was provided with a container to empty their urinary catheter bag because they could not access the toilet or sink in the bathroom. Staff interviews confirmed that the bathroom doors on certain units were too small for most wheelchairs, and the facility attempted to place only ambulatory residents in those rooms due to the limited doorway size.
Resident Placed in Room Without Bathroom Facilities
Penalty
Summary
A deficiency was identified when a resident was temporarily placed in a room known as the Country Store, located in the secure memory care unit, which did not have a sink or toilet. Staff interviews confirmed that all regular rooms in the secure unit were occupied, and the resident was placed in the Country Store as a temporary measure. The area was described as two open spaces used for storage, lacking both a sink and a bathroom. Staff reported that they monitored the resident closely and assisted with toileting by escorting the resident to a shower room at the other end of the unit. Observations confirmed the absence of bathroom facilities in the Country Store during the period the resident was housed there.
Failure to Maintain Functional Bathing Facilities
Penalty
Summary
The facility failed to ensure it was equipped with functional bathing facilities/shower rooms, affecting all 90 residents. The facility's preventive maintenance policy emphasizes the importance of maintaining fixtures and equipment in good working order. However, during a tour, it was observed that one of the two designated shower rooms was taped off and marked as out of order, while the other was operational. No resident rooms had individual bathing facilities. Multiple residents reported that the shower rooms were non-functional for varying periods, with some stating they had no access to a shower for up to two weeks. The Ombudsman confirmed that one shower room had been non-functional for at least eight months, and the other had been out of order for around two weeks, leaving residents without a place to shower for ten days. The facility administrator, who had been in the position since May 1, 2024, confirmed that both shower rooms were unavailable due to plumbing issues from April 24, 2024, through May 3, 2024. The administrator also noted that there was no system in place for maintenance work orders. This lack of functional bathing facilities and the absence of a maintenance system led to significant inconvenience and potential hygiene issues for the residents.
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