Failure to Maintain Safe, Clean, and Homelike Resident Rooms and Shower Area
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment for multiple residents and in a shared shower room. For one cognitively intact resident with diagnoses including acute kidney failure, major depressive disorder, and type 2 diabetes, surveyors observed on multiple dates that the wall surrounding the windowsill was broken and crumbling, allowing outside air to enter the room, and that the ceiling tile above the window was stained yellow/orange. The resident reported feeling cold from the draft, was unable to get out of bed without assistance, and expressed a desire to have the stained ceiling tile replaced. Facility staff, including an LPN, a maintenance associate, and the Plant Operations Manager, acknowledged that the wall and window had been in this condition for at least two months, were not homelike, and should have been repaired to prevent drafts. Another resident, with severe cognitive impairment and diagnoses including traumatic brain dysfunction, dementia, and anxiety disorder, was observed via a time-stamped photograph provided by a family member lying in bed with an open window in the room, uncovered feet, and shivering. The family member reported that the resident felt cold to the touch and that a tray of food from the previous night, consisting of mashed potatoes and gravy, remained untouched and wrapped in aluminum foil. A CNA later admitted to opening the window due to odor and heat in the room, was unsure how long it remained open, and stated that the resident had been completely covered with a sheet and two blankets when the CNA left. The DON confirmed being informed of the situation by the family member and stated the window should not have been opened. The Regional Nurse Consultant/IP reported there was no policy explicitly covering a safe and homelike environment. A third resident, with chronic kidney disease, major depressive disorder, anxiety, and moderately impaired cognition, was found on several observations to have dusty floors around the bed, a white powdery substance on the floor, a large wood floorboard missing under the bed, and fall mats covered with food debris and trash. Facility staff, including an LPN, the Administrator, and the Plant Operations Manager, stated they expected resident room floors to be clean, free of debris, and with intact flooring, and the Plant Operations Manager acknowledged awareness of the missing flooring. Additionally, repeated observations of a second-floor shower room showed used briefs in trash cans without liners, toilet riser seats smeared with stool and brown matter beneath them, no toilet paper in the dispenser, puddles of clear liquid on the floor near toilets, and a strong urine odor. A housekeeper reported that shower rooms were cleaned once daily, including toilets, floors, toilet paper refills, and trash removal, while the Administrator and DON stated the shower room should be clean, odor-free, and adequately supplied.
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