Failure to Maintain Safe, Sanitary, and Comfortable Environment During Odor and Renovation Issues
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment on two of four halls, specifically Hall 300 and Hall 400. On Hall 300, persistent foul odors were observed, described as urine, bowel movement, and body odor, emanating from a specific resident room and spreading into the hallway and other rooms. Multiple staff, residents, and family members confirmed the ongoing odor issue, with some stating it had been present for an extended period. The source of the odor was attributed to two residents who consistently refused care, including bathing, wound care, and incontinence care. Despite additional cleaning and the use of odor neutralizers, the problem persisted, and staff were unclear about any effective interventions being implemented by facility management. On Hall 400, the facility failed to ensure that construction and renovation activities were conducted safely and with proper communication. Residents and staff were not informed in advance about the nature of the work, which involved spraying a texturizer on ceilings, creating dust and loud noise. Plastic barriers were erected, but they did not fully seal resident rooms, allowing dust and sprayed material to enter. Some residents were confined to their rooms without being offered masks or the option to relocate, and staff were not provided with information or appropriate personal protective equipment. The construction activities also resulted in at least two residents not receiving scheduled wound care, as the wound care physician was unable to access their rooms due to the barriers. Additionally, the facility failed to maintain the physical environment in the dining area, where a door was propped open with a zip tie and an extension cord was zip tied to the door hinges, preventing the door from closing. This situation had persisted for approximately two months, and staff were aware of the issue but had not addressed it. Throughout the report, staff interviews revealed a lack of communication and awareness regarding environmental safety and infection control practices during renovations, as well as ongoing issues with odor management and resident care refusals.