Failure to Maintain Clean Environment and Equipment
Penalty
Summary
The facility failed to maintain a clean environment, including resident rooms and mechanical lifts, as observed during an initial tour with the Assistant Director of Nursing. In one resident's room, the floor was dirty with visible crumbs and dust buildup, the toilet had yellow and brown streaks on the outer bowl, and there was a brown spot on the wall that appeared to be dried feces. Additional observations included dust buildup on baseboards, fireplaces, and tables in common areas, as well as visible dirt and debris on mechanical lifts such as sit-to-stand and Hoyer lifts. These findings were verified by facility staff at the time of observation. Interviews with the Environmental Services Supervisor and housekeeping staff revealed inconsistencies in cleaning schedules, with some rooms cleaned every three days and others daily or every other day. Housekeeping services were subcontracted, and there was a lack of a set schedule for cleaning certain areas such as baseboards and fireplaces. Documentation review showed that the facility's stated goal was daily thorough cleaning, but audit tools and workflow sheets indicated cleaning was performed as needed or when visible dirt was present. Photos provided by the cleaning contractor confirmed the presence of unclean conditions in the resident's bathroom, and meeting minutes reflected ongoing issues with housekeeping services.