Failure to Maintain Safe and Homelike Environment for Two Residents
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for two residents. For one resident, who had diagnoses including pneumonia, COPD, and type 2 diabetes mellitus, and was cognitively intact and able to express needs, the facility did not ensure that bilateral fall mats were in good repair. Observations revealed that both floor mats had multiple tears, and the resident stated the mats were old and needed replacement. A CNA confirmed the mats were torn and acknowledged that staff should notify maintenance for replacement, as torn mats do not look good and do not provide a homelike environment. The DON also confirmed that staff are required to report such issues for prompt replacement, and that failure to do so does not provide a clean and homelike environment for the resident. For another resident, who had diagnoses including C. diff enterocolitis, hemiplegia, and hemiparesis, and was cognitively intact with impaired vision, the facility failed to maintain cleanliness in the resident's room. The resident preferred to keep urinals on the bedside table and have the room cleaned later in the day. During observation, a sticky yellowish substance, possibly urine, was found on the floor beneath the urinal. A treatment nurse confirmed the floor was sticky and stated it was the responsibility of all staff to ensure the room was clean and homelike. The DON also stated the floor should be clean and free of stains, and that failure to maintain cleanliness does not promote a homelike environment. The facility's policy on providing a homelike environment, last reviewed in May 2025, requires staff to provide a safe, clean, comfortable, and homelike setting, emphasizing person-centered care and a sanitary, orderly environment. Both incidents demonstrated a failure to adhere to this policy, as staff did not ensure the prompt replacement of damaged equipment or maintain cleanliness in resident living spaces.