Failure to Maintain Clean, Comfortable, and Accessible Resident Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for multiple residents, as evidenced by direct observations and resident interviews. One resident with moderately impaired cognition was found with a soiled incontinent brief on the bathroom floor, reporting difficulty accessing the bathroom due to the placement of his wheelchair and lack of a trashcan. The resident stated he had requested adjustments to the room layout but was told the wheelchair and bed could not be moved. The Assistant Director of Nursing also experienced difficulty entering the bathroom due to the room's layout but did not attempt to resolve the obstruction. Another resident, dependent on staff for mobility and transfer, had personal possessions out of reach and reported that staff placed facility items in his dresser, leaving no room for his belongings. The resident stated that staff would not help him organize or store his items, and a CNA indicated that since the resident could speak for himself, he only needed to ask for help. Additional observations included a resident requiring a mechanical lift who was found with soiled bedding and an exposed mattress, reporting discomfort and lack of an air mattress as expected. Staff interviews revealed inconsistent bedding changes and a lack of responsiveness to the resident's needs. A further resident with muscle wasting and pressure ulcers was unable to reach his phone charger or room phone due to bed placement and reported that staff would not move the bed or provide alternative solutions. Observations also noted a plastic bag containing a bedpan and paper towels tied to a siderail in a shared bathroom, with staff indicating it was garbage but not promptly removed. These findings collectively demonstrate the facility's failure to maintain a safe, clean, and accessible environment that supports residents' independence and comfort.