Failure to Maintain a Safe, Clean, and Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for eight of sixteen sampled residents. Observations revealed multiple deficiencies in resident rooms, including missing thresholds, unrepaired holes and dents in walls, torn and missing wallpaper, blood stains and scuff marks on walls, strong urine odors, and curtains with blood stains left hanging. These environmental issues were directly observed by surveyors and confirmed by staff interviews, with both the Infection Prevention Nurse and the Director of Maintenance acknowledging that these conditions did not meet homelike standards and posed potential hazards such as tripping and fire risks. Several residents affected by these deficiencies had significant medical and cognitive impairments. For example, one resident with a history of falls, fractures, diabetes, and severe cognitive deficit was exposed to persistent urine odors due to urine-soaked clothing left to dry in the bathroom. Another resident with muscle weakness, major depressive disorder, and severe cognitive deficit reported that her room always smelled like urine, even after cleaning. In another room, residents were exposed to a dangling electrical outlet, missing bathroom thresholds, and scuffed walls, with one resident expressing concern about the fire risk and not knowing repairs could be requested. Additional observations included a room with a large hole and dent in the walls behind residents' beds, and another room where blood splatter stains were present on both the wall and privacy curtain. One resident expressed frustration and emotional distress over repeated, unaddressed requests to have blood stains cleaned and curtains changed. Staff interviews confirmed that these conditions were not acceptable, with the Housekeeping Manager acknowledging that blood stains posed an infection issue and that the room was not cleaned to expectations. The facility's own policy required a clean, sanitary, and orderly environment in good condition, which was not maintained in these instances.