Failure to Maintain Safe, Clean, and Homelike Environment During Odor and Construction Issues
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment on two of its four halls, specifically Hall 300 and Hall 400. On Hall 300, persistent foul odors of urine, feces, and body odor were observed, particularly emanating from the room of two residents with significant wound care needs and a history of refusing care such as bathing, grooming, and wound treatment. Multiple interviews with staff, residents, and family members confirmed that the odor was longstanding, noticeable throughout the hallway, and had not been effectively addressed by increased cleaning or the use of odor neutralizers. Housekeeping staff reported cleaning the affected rooms twice daily and using multiple bottles of odor neutralizer per week, but these efforts did not resolve the issue. Residents and family members expressed dissatisfaction with the living conditions, describing the environment as unpleasant and not reflective of a homelike setting. On Hall 400, the facility failed to ensure that ongoing construction and renovation activities did not negatively impact residents' comfort and access to care. During the renovation, a section of the hallway was closed off with plastic sheeting, and workers were observed spraying texturizer on the ceilings while wearing N95 or respirator masks. The area was filled with dust and noise, and residents remained in their rooms behind incomplete plastic barriers, with no clear communication or protective measures provided to them or the staff. Staff members were unaware of the nature of the work or the need for personal protective equipment, and residents were not given the option to move or provided with masks. The construction activities resulted in at least two residents missing scheduled wound care visits, as the wound care physician was unable to access their rooms due to the barriers. The report details that the facility administration did not provide adequate notice or information to staff or residents regarding the renovation activities, and there was a lack of signage indicating the type of work being performed. Staff interviews revealed confusion and concern about the safety of the environment, and residents reported increased discomfort, including noise, dust, and respiratory symptoms. The administration acknowledged the renovations but was unable to specify the materials being used or the necessary precautions. The facility also failed to provide a policy for maintaining a homelike environment when requested by surveyors.