Failure to Maintain Clean and Homelike Resident Environments
Penalty
Summary
Surveyors identified a failure by the facility to maintain a clean, safe, and homelike environment for four residents with significant physical and cognitive impairments. Observations revealed that resident rooms contained trash, food particles, soiled linens, dust, and sticky substances on floors and furniture. Specific findings included food particles and red stains on a resident's bed, sticky floors, and clutter such as gowns and briefs left out in rooms. Another resident's room had stained blankets, latex gloves, and various personal items scattered on surfaces and chairs, as well as a rolled mattress and foot splint obstructing access to the closet. Additional observations included a resident with food in her hair, on her gown, and on her bed, a sticky floor, and a noticeable urine odor in the room. Items such as clean briefs, house shoes, and hair covers were left out on nightstands and chairs. Another resident's room had trash on the floor, non-skid socks strewn about, unfolded clothes on a nightstand, and a dead fly and dust on the window sill. These conditions were present despite the residents' documented deficits in activities of daily living (ADLs), which required staff assistance for maintaining cleanliness and order in their living spaces. Interviews with staff confirmed that nursing and housekeeping personnel were responsible for ensuring rooms were clean and free of clutter, and that linens and personal items should be properly stored. Staff acknowledged that rooms should not have trash on the floor, cluttered surfaces, or clean briefs left out, especially for residents dependent on staff for room maintenance. Facility policies also required maintaining a sanitary, odor-free, and comfortable environment, but these standards were not met as evidenced by the survey findings.