Failure to Maintain Safe, Comfortable, and Odor-Free Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by two residents experiencing significant discomfort due to excessive heat and persistent urine odors in their living areas. One resident, with multiple diagnoses including dementia and end-stage renal disease, was found to be overheated and weak after wearing multiple layers of clothing on a hot day. Staff and the resident's power of attorney reported that the room was extremely hot, and the facility did not provide a fan, requiring the family to purchase one. The environmental services director confirmed there was no monitoring of room temperatures, and the facility had no documentation to ensure temperatures remained within regulatory limits. Additionally, the same resident's room was repeatedly noted to have a strong urine odor, with wet bed sheets and soiled pads left unaddressed after the resident was moved from bed. Staff acknowledged the presence of urine odor and wet linens, and the director of nursing confirmed that such linens should have been changed immediately. The resident's representative reported ongoing issues with urine odors and soiled pads, indicating a pattern of inadequate housekeeping and maintenance services. Another resident, who was dependent on staff for mobility and hygiene, reported that the temperature in his room was unbearable on several days, and requests for a fan or air conditioning were denied. The resident stated that he preferred to keep his door closed for privacy, which exacerbated the heat, and he was uncertain if a window air conditioner he ordered would be permitted. These findings demonstrate the facility's failure to provide adequate temperature control and maintain odor-free, comfortable living conditions for its residents.