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F0584
D

Failure to Maintain Clean and Homelike Resident Room Environment

Duluth, Minnesota Survey Completed on 04-17-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a resident with a primary diagnosis of orthopedic care following a right lower leg amputation reported that his room was too dark, had stains and holes in the walls, and that one of the blinds was not functioning. Observations confirmed several screw holes between the windows, multiple brownish-black streaks on the wall behind the bed and chair, and dried brown substances on the light fixture over the sink. The resident stated these issues bothered him and that he had complained to staff. Interviews with maintenance and housekeeping staff revealed there was no routine schedule for checking rooms for maintenance issues, and deep cleaning was performed only when a room was vacated or annually. Maintenance staff were unaware of the holes in the wall and deferred responsibility for stains to housekeeping, while housekeeping staff acknowledged the stains but indicated that cleaning the light fixture would require maintenance. The facility's policy on a homelike environment did not address wall repairs, and the administrator confirmed knowledge of the room's condition but did not inspect it at the time.

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