Failure to Provide Clean, Sanitary, and Prepared Room Before Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, functional, sanitary, and comfortable environment in a resident room that was reassigned to a cognitively and visually impaired resident. The resident, an older woman with COPD, dementia with behavioral disturbance, macular degeneration causing severe visual impairment, difficulty walking, respiratory failure, and a cognitive communication deficit, was initially admitted earlier in the month and most recently readmitted on 12/20/25. Her care plan documented impaired visual function and severe visual impairment, and she had a recent history of multiple falls, including both witnessed and unwitnessed events, one of which resulted in injury. Her cognitive status declined from a BIMS score of 15 (normal cognition) on the MDS to a BIMS score of 6 (severe cognitive impairment) on an updated assessment completed on 12/27/25. On 12/30/25, the resident was moved from Room A to Room B on the skilled hallway. Room B had previously been occupied and contained items and environmental conditions that were not addressed before the transfer. The resident’s responsible party later reported finding a bloody pillow in the resident’s wheelchair, clothing items in the drawers belonging to a previous resident, and fecal matter on the bottom of the other bed, stating that the room did not appear to have been cleaned and looked like it had been used as storage. Photographic evidence submitted by the responsible party showed a pillow with bright red blood on the pillowcase and pillow, positioned across the handlebars of a wheelchair in Room B, with an oxygen machine visible in the background. Surveyor observation of Room B showed two beds, a dresser pushed into a corner, and a large electric geriatric wheelchair with foot holders and other wheelchair parts stored in the far corner. The walls and baseboards were pale yellow with extensive black and grey scuff marks, including deep scuffs exposing white drywall, and dried liquid droplets on the wall next to one bed. An oxygen machine dated 12-29-25 was on the nightstand of one bed. The closet contained a trash bag full of clothes and multiple garments labeled with a previous resident’s name and room number, and a dark reddish/purple circular stain was present on the carpet near the front of the room. Staff interviews revealed that the room should have been deep cleaned and cleared of previous residents’ belongings before the transfer, that housekeeping and maintenance processes were not completed as intended, and that clothing and a large motorized wheelchair from previous residents remained in the room. The facility’s policy on Physical Environment stated the purpose was to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, which was not met in this instance.
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