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F0584
E

Failure to Maintain Safe, Clean, and Homelike Environment

Middleton, Wisconsin Survey Completed on 05-07-2025

Penalty

No penalty information released
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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 identified multiple failures by the facility to provide a safe, clean, comfortable, and homelike environment for residents, as required by policy. In the kitchen, a door connecting the dish room and main dining room was found detached from its hinges and leaning against the kitchen sink for an extended period. Staff interviews and email records revealed that the issue had been ongoing for several months, with maintenance and management aware of the problem but unable to resolve it due to delays in ordering a replacement door. The lack of a functioning door raised concerns about sanitation and potential cross-contamination between the kitchen and dining areas. In resident rooms, meal trays were observed left unattended after residents had finished eating and left the room. Interviews with staff indicated that tray removal was based on resident preference, but at least one resident expressed discomfort with trays being left in her room. This practice did not align with maintaining a clean and homelike environment for residents. The facility's shower rooms were found to be cluttered, unclean, and not homelike. Observations included multiple lifts and shower chairs stacked in the rooms, unlabeled and open bottles of skin and hair cleanser, dust, stained items, and personal belongings left out. In one shower room, a ceiling tile was dripping water, and the shower was not fully functional, with a missing handle and water leaking from the area. Staff interviews confirmed awareness of these issues, and both the DON and NHA agreed that the shower rooms were neither clean nor homelike. Additional observations in another shower room included a dirty toilet, a commode bucket with dried residue, lack of hand sanitizer, and soiled towels and sponges left out.

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