Failure to Maintain Safe, Clean, and Homelike Resident Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment on multiple units. Observations over two days showed that resident rooms on three of four units lacked basic linens such as washcloths, bath towels, and hand towels. A resident representative reported that there was never any linen in one resident’s room to assist with bathing during the resident’s approximately six‑week stay. The DON stated that staff were expected to stock resident rooms with washcloths and clean linen as required, and the director of housekeeping and an RN confirmed that clean linens were available in the clean supply storage and should be supplied from there when needed. The same resident representative also reported that the resident’s bathroom had no door in place during the entire stay in a secure unit room, and subsequent observation months later showed that the room remained without a bathroom door. Surveyors also found environmental safety and cleanliness issues related to maintenance. In one room, broken tiles under both toilet riser legs appeared dirty and had a urine odor. The resident in that room stated they had reported the broken tile to maintenance over two months earlier and were told the repair was being delayed due to planned remodeling. Housekeeping staff reported that they would notify maintenance and supervisory staff when items, including doors, required repair. The maintenance director confirmed awareness of the broken tiles and stated that repair was pending a planned remodel, and further stated that the bathroom door had been on order for a couple of months.
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