Improper Storage of Personal Care Items and Inadequate Hot Water in Resident Bathroom
Penalty
Summary
Surveyors observed that personal care items, including bedpans, urinals, and toilet hats, were not stored in accordance with facility policy in multiple shared bathrooms. These items were found unlabeled, uncovered, and wedged inside metal racks or railings, sometimes in contact with walls or with other objects such as clothing. Staff interviews revealed that nurse aides were responsible for labeling, covering, and storing these items, but could not explain why the policy was not followed. The infection prevention nurse and the director of nursing both confirmed the expectation for proper storage and labeling, but were unable to account for the observed lapses. Additionally, a resident with a diagnosis of malignant neoplasm of the bladder and blindness was found to have inadequate hot water in their bathroom sink. Multiple temperature checks over several days showed the hot water was consistently far below acceptable levels, requiring staff to bring in warm water from other rooms for bathing. Interviews with maintenance staff and the administrator revealed a longstanding issue with the hot water supply to this room, stemming from an improper connection made during a renovation years prior. The problem had persisted because a repair was never scheduled, and the water would only become hot after running for an extended period or by manipulating water flow in other areas. The facility's failure to ensure proper storage of personal care items and to maintain safe and comfortable water temperatures in resident bathrooms resulted in an environment that did not meet standards for cleanliness, comfort, and safety. These deficiencies were identified through direct observation, staff interviews, and review of facility policies and records.