Failure to Maintain Safe, Clean, and Homelike Environment in Memory Care Unit
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in the memory care unit and in two resident rooms. One resident with severe cognitive impairment, total dependence for personal care, and multiple neurological and physical diagnoses had a large hole in the wall above the bed, approximately the size of a twelve‑ounce can. The Maintenance Director stated the damage was caused by the bed being raised and lowered during personal care, acknowledged the wall had been repaired multiple times, and confirmed that the current hole had not been repaired and the surrounding drywall had not been repainted, resulting in a non‑homelike appearance. Another resident with moderate cognitive impairment, dependence on staff for toileting and personal care, and frequent bowel and bladder incontinence had a brown substance that appeared to be bowel movement on both the front and back handles of the bathroom door on two consecutive observations. An RN confirmed the substance appeared to be bowel movement on both handles. Housekeeping staff reported that she cleaned resident rooms and bathrooms weekly and as needed and that facility policy required doorknobs and similar high‑touch surfaces to be cleaned at least daily and more often as needed. In the common television area of the memory care unit, surveyors observed multiple holes and scratches in the drywall from chairs, several brown marks of varying sizes near an electrical outlet, and missing wall trim along portions of the wall, all of which were confirmed by the Maintenance Director.
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