Failure to Maintain Clean and Homelike Environment for Multiple Residents
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for three residents as evidenced by multiple observations and interviews. One resident with COPD and depression, who had contracted fingers and refused hand care due to pain, was found with a call light button covered in brown, crusty matter on several occasions. Staff interviews revealed that while housekeeping and nursing assistants were aware of the need to clean high-touch surfaces like call lights, cleaning was only performed when dirt was noticed, rather than on a consistent schedule. Another resident with COPD and heart failure, who used a wheelchair, was observed multiple times with dried fluid on the left side of the wheelchair and seat cushion. There was no documented schedule for routine wheelchair cleaning, and staff were unclear about whose responsibility it was to clean and document wheelchair maintenance. A third resident, who was cognitively intact and had high blood pressure and anxiety, was reported by a family member to have had the same sheets on their bed for two weeks, with subsequent observations confirming unchanged bedding. Staff interviews indicated that sheets were only changed on shower days or when visibly soiled, with no evidence of more frequent changes.