Failure to Maintain Clean, Safe, and Homelike Environment for Residents
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment for multiple residents. Observations included soiled linens, dirty towels, food, clothing, and various items scattered on the floors of several resident rooms. In one instance, a resident's bed had yellowish/brown stains on the sheets and pillowcase, and the floor was cluttered with food, personal items, and trash. Residents and their representatives voiced concerns about the cleanliness of their rooms and personal equipment, such as wheelchairs, which were observed to be dirty with dried food particles and stains. Interviews with staff revealed a lack of clarity regarding responsibility for cleaning certain items, particularly wheelchairs. Housekeeping staff, CNAs, and other personnel were unsure about who was responsible for cleaning wheelchairs or how often this should occur. Some staff recalled that there was previously a schedule for wheelchair cleaning, but it was no longer in use, and no one could confirm the current process. This lack of a defined cleaning protocol contributed to the ongoing issues with unclean equipment and resident environments. Additional environmental deficiencies were noted, such as water stains and a cut-out section in a resident's ceiling due to a leaking roof, cobwebs above beds, and various debris including straw wrappers, crumbs, and personal items on the floors of multiple rooms. Maintenance issues, such as unresolved roof leaks and water damage, were acknowledged by facility leadership but remained unaddressed at the time of the survey. Residents with varying levels of cognitive impairment and complex medical conditions were affected by these deficiencies, with several expressing dissatisfaction with the cleanliness and upkeep of their living spaces.