Failure to Maintain Homelike Environment Due to Improper Storage and Persistent Odors
Penalty
Summary
The facility failed to provide a homelike environment for two residents by not ensuring proper storage of personal care equipment and not maintaining a room free from persistent odors. For one resident with a pelvic fracture and dementia, observations revealed a grey bedpan wedged between the wall and a grab-bar next to the toilet, and two clear graduated containers placed upside down on the toilet tank. The resident's denture cup, toothpaste, and toothbrush were also stored on a shelf over the sink rather than in the bedside dresser as indicated by staff. Interviews with nursing staff and aides confirmed that these items were not stored according to facility expectations, and there was confusion about ownership and proper storage procedures. The facility was unable to provide a policy for the storage and dating of bedpans and containers used for urinary catheter care. For another resident with hypertension, diabetes, and PTSD, the facility did not ensure the resident's room was free from urine odors. Multiple observations over several days identified a persistent urine-like odor in the room. Staff interviews indicated that the odor may have been due to soiled sheets or urine seeping into the tiles, and that the responsibility for addressing the odor was not clearly defined among nursing and housekeeping staff. Despite the beds being made without visible soil, the odor persisted, and staff acknowledged awareness of the issue prior to the surveyor's observations. These deficiencies were identified through clinical reviews, direct observations, and staff interviews, which demonstrated lapses in maintaining a clean, comfortable, and homelike environment for residents. The lack of clear policies and inconsistent practices regarding the storage of personal care equipment and the management of persistent odors contributed to the failure to honor residents' rights to a safe and homelike living space.