Failure to Maintain Safe and Sanitary Resident Environments Due to Hoarding and Behavioral Issues
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in two resident rooms, as evidenced by direct observations and record reviews. In one instance, a resident with diagnoses including dementia, obsessive-compulsive disorder, and a history of traumatic brain disorder was found in a room with significant clutter, old food, and soiled linens. The resident's room contained multiple Styrofoam cups, food containers with old food, and stained linens and clothing, all emitting a strong foul odor detectable from the hallway. The care plan noted the resident's tendency to hoard and become combative when staff attempted to clean, and staff documentation confirmed repeated episodes of combative behavior during personal care and cleaning attempts. Another resident, diagnosed with dementia, bipolar disorder, and anxiety, was observed in a similarly unsanitary environment. The resident's room contained a cup of urine, food debris, stained and wet linens, and a privacy curtain with a foul odor. The resident was also noted to hoard food and refuse personal care, including showers. Staff interviews confirmed that the resident frequently left soiled items throughout the room and would become aggressive when staff attempted to clean or remove items. The odor from the room was strong enough to be noticed in the hallway, and staff reported reluctance to enter the room due to the smell and the resident's behavior. Housekeeping staff reported difficulty maintaining cleanliness in these rooms due to the residents' behaviors, including hoarding and aggression. Despite daily cleaning assignments, the rooms were not adequately maintained, and deep cleaning was not performed as needed. Facility leadership acknowledged the ongoing issues with these rooms and the impact on other residents but expressed uncertainty about how to resolve the situation.