Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
A deficiency was identified when a resident, recently readmitted with a diagnosis of congestive heart failure and skin openings on both legs, was found to have soiled and stained bed linens several days after returning to the facility. During an observation, the resident's mattress was only partially covered with a sheet, and both the mattress and additional sheets displayed large dried brown, red, and yellow stains. The resident reported that the stains were from coffee, blood from leg wounds, and food or juice spills, and stated that the bed sheets had not been changed since readmission several days prior. An interview with the nursing assistant assigned to the resident revealed that, as an agency staff member, they were unaware of when the bed linens were last changed and confirmed that the sheets had not been changed that morning. The Director of Nursing was informed of these findings. The facility failed to provide a clean, comfortable, and homelike environment for the resident, as required by regulation.