Failure to Maintain Clean and Homelike Environment for Residents and Unit
Penalty
Summary
Facility staff failed to maintain a clean and homelike environment for two residents who were dependent on wheelchairs for mobility. Both residents' wheelchairs were observed on multiple occasions to be visibly soiled with dried white and brown substances, food debris, and stains. Despite the facility's policy requiring regular cleaning of wheelchairs, there was no evidence that these wheelchairs had been cleaned as required. Interviews with staff revealed confusion regarding responsibility for cleaning, with housekeeping, nursing, and the director of nursing providing inconsistent statements about cleaning schedules and duties. The Housekeeping Manager confirmed that the wheelchairs were not sanitary or homelike and could not provide documentation of recent cleaning. In addition to the issues with wheelchair cleanliness, the facility failed to maintain resident care equipment and the building in a clean condition and good repair on one unit. Observations included significant wall damage, missing baseboard trim, exposed insulation, and unpainted drywall repairs in resident rooms. There were also instances of dried food substances on walls and bedside tables that remained uncleaned over several days. Residents and their representatives reported that these areas had not been cleaned or repaired in a timely manner, and staff interviews confirmed that there was no formal process for environmental rounds or systematic notification of maintenance needs. Facility policies and cleaning schedules indicated that wheelchairs should be cleaned bi-monthly and that daily cleaning tasks included wiping down bedside tables and walls. However, the lack of adherence to these policies and the absence of clear communication and accountability among staff led to persistent unsanitary conditions and unrepaired environmental damage. These deficiencies were directly observed by surveyors and confirmed through staff and resident interviews.