Failure to Maintain Cleanliness and Organization in Resident and Therapy Areas
Penalty
Summary
The facility failed to maintain a clean and comfortable environment for residents, as evidenced by multiple deficiencies in cleaning and organization. In the therapy gym, equipment such as Nu Step machines and Omni Cycles were observed to have debris, sand-like buildup, hair, and deteriorating materials, despite claims that equipment is wiped down between uses and deep cleaned monthly. The cleaning schedule lacked specific tasks, and the observed buildup suggested inadequate cleaning practices. Additionally, the seat and handle covering on one machine were damaged and deteriorating, further contributing to unsanitary conditions. In resident care areas, a resident who was totally dependent on staff and cognitively impaired was found with a soiled gown and a blanket with a large brown smear near the face, and the room had visible black wheelchair marks and chipped paint. Another room contained hygiene items and a bedpan left behind by a discharged resident, and several rooms on the 100 Hall were noted to be cluttered with resident items stacked on floors and surfaces, making the environment appear unkempt. These observations indicate a failure to ensure timely removal of soiled linens, proper disposal of hygiene products after discharge, and adequate decluttering and cleaning of resident rooms.
Plan Of Correction
Element Three: Administrator/Designee completed education with the IDT members who conduct room rounds to ensure any identified cluttered rooms are addressed as well as any black marks or paint chips are identified. Housekeeping Supervisor/Designee completed education with the Housekeeping staff to ensure all rooms identified with clutter are addressed immediately and personal belongings are removed timely when residents are discharged from the facility and room is clean and ready for new resident. Administrator/Designee completed education with the Housekeeping staff and Therapy staff on cleaning of gym equipment. Administrator/Designee completed education with the Nursing staff in regards to removal of soiled clothing/gowns and linen are removed from resident beds and placed in appropriate bin to be sent to laundry and removing clutter from rooms. Any staff not educated by May 20, 2025 will be educated on their next scheduled shift. Element Four: Housekeeping Supervisor/Designee will complete random weekly audits X4 weeks of resident rooms to assure rooms are free of clutter, soiled linen has been removed and discharged residents' personal hygiene products have been removed, no black markings or chipped paint with findings submitted to Administrator who will report findings to QAPI for review and recommendations. Therapy Director/Designee will completed random weekly audits X4 weeks of therapy equipment to ensure cleanliness, with findings submitted to QAPI for review and recommendations. Element Five: The Administrator is responsible for maintaining compliance.