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F0584
E

Failure to Maintain Cleanliness of Tube Feeding Poles

West Allis, Wisconsin Survey Completed on 05-01-2025

Penalty

Fine: $145,850
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors found that the facility failed to maintain a safe, clean, comfortable, and homelike environment for five residents who used tube feeding poles. Over multiple days, the bases of these residents' tube feeding poles were observed to have dried feeding residue, with some poles having significant accumulations on multiple legs and even clumps of dried feeding. Observations were made on several occasions, and in one instance, a family member reported that the pole had been dirty for months, making it difficult to adjust due to the buildup. Interviews with facility staff revealed confusion regarding responsibility for cleaning the tube feeding poles. A housekeeping aide stated uncertainty about whether cleaning the poles was her responsibility or that of the CNAs, and admitted that she had not cleaned any of the poles in the past month. The RN Supervisor and Administrator both indicated that housekeeping was responsible for cleaning the poles, but the facility's provided cleaning policy did not address tube feeding poles specifically. No additional policy or explanation was provided for the lack of cleaning, and the issue persisted despite being brought to the attention of facility leadership.

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