Failure to Maintain Safe, Clean, and Functional Resident Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment for multiple residents. One resident’s room was observed in disarray, with a strong urine odor, dirty clothes on a chair with clean linen placed on top, soiled underwear in a corner, trash on the floor, and the bed controller on the floor out of the resident’s reach. The DON confirmed the urine smell and the general disarray, including dirty linens, dirty clothes, and trash in the room. Another resident’s room had bed sheets soiled with a dark substance at the head of the bed, and medical equipment including two suction machines and an oxygen concentrator splashed with dark substances, with fluid remaining in one suction canister. The refrigerator in the room had a layer of dust on top and sticky substances covering most interior surfaces. This resident reported that he usually changed his own sheets if they were changed at all and that he had requested laundry service for over a week without response, leaving him with only one visibly soiled shirt and pair of pants while dirty clothes accumulated in his closet. An LPN verified the room conditions, acknowledged the resident’s request for laundry that she had not communicated, and was unsure who was responsible for cleaning medical equipment. A housekeeper stated she had cleaned the room about an hour earlier, described housekeeping tasks as floors and dusting, and indicated CNAs were responsible for linens but was also unsure who cleaned medical equipment. A third resident reported falling twice in the bathroom due to a toilet seat not being attached, and also reported a non-flushing toilet requiring a plunger each time and a leaking sink. Observation of this bathroom showed a loose toilet seat that slid to the side when pressure was applied to the handrails, which the DON confirmed.
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