Failure to Maintain Clean, Homelike Environment and Address Odors
Penalty
Summary
Facility staff failed to maintain a safe, clean, comfortable, and homelike environment for residents across multiple nursing units and common areas. Persistent strong urine odors were observed in two of three nursing units and one of three common hallways over several days, despite ongoing cleaning efforts by housekeeping staff. The director of housekeeping acknowledged the difficulty in controlling odors, particularly in areas with residents requiring frequent changing and in units with poor ventilation. The presence of these odors was confirmed by both staff and surveyors during multiple observations. In addition to odor issues, staff failed to maintain privacy curtains in a clean and sanitary condition for several residents. Observations revealed privacy curtains hanging off their tracks and touching the floor, as well as curtains with visible brown stains and debris. These conditions persisted over multiple days and were not addressed until brought to the attention of the director of environmental services during the survey. The facility's policy requires a clean, sanitary, and orderly environment, including the maintenance of privacy curtains, but these standards were not met for the affected residents. Furthermore, staff failed to provide a clean environment for a resident who was left with a bloody pillowcase in contact with his body for at least two days. The resident, who was totally dependent on staff for turning and positioning and was cognitively intact, reported that no staff member offered to change the soiled pillowcase overnight. Both an LPN and a CNA interviewed during the survey agreed that this was not a clean or homelike environment for the resident. These deficiencies were observed and confirmed by surveyors and facility leadership during the survey process.