Failure to Maintain Clean and Homelike Bathing Areas
Penalty
Summary
Surveyors identified a failure to maintain a clean and homelike environment on two of three units, specifically on the second and fourth floors. During tours, the surveyor observed multiple sanitation and housekeeping deficiencies in the central bath areas. These included a sink filled with discarded items such as an isolation gown, black pad, wash sponge, and basin; a shower bed with hair clippings, toilet paper, personal care products, and debris; visible water on the floor inside and outside the shower stall; and the presence of brown, green, and black substances in various corners and on the floors of the shower stalls. Additional findings included wet towels and socks left in the shower, a build-up of unknown debris and hair in the shower drain grate, and missing molding with a hard brown substance on the wall. Interviews with staff revealed a lack of clarity regarding responsibilities for cleaning and maintaining the shower areas. An LPN stated that CNAs were responsible for gathering residents' belongings after showers, and that housekeeping was responsible for cleaning the shower rooms. However, staff were unsure about the nature of the substances found in the showers and who was responsible for cleaning specific areas such as the shower grate. Staff confirmed that the observed conditions did not create a homelike environment for residents. A review of the facility's housekeeping and environmental services job descriptions indicated that housekeeping staff were expected to perform cleaning and sanitation of resident rooms and common areas, conduct regular inspections, and collaborate with other team members to maintain cleanliness. The director of environmental services was responsible for supervising housekeeping and laundry activities to keep the facility orderly, clean, and sanitary. Despite these outlined responsibilities, the observed deficiencies indicated that these standards were not met in the central bath areas on the affected units.
Plan Of Correction
F584 Safe/Clean/Comfortable/Homelike Environment ELEMENT ONE: CORRECTIVE ACTION: The second and fourth floor Central Baths were cleaned and sanitized by housekeeping on 5/9/25. Noted black, brown, green, and red substances were removed from the second and fourth floor Central Baths on 5/9/25. Personal hygiene and linen items were removed from the second-floor Central Bath sink on 5/9/25. Hygiene and toiletries were removed from the second-floor Central Bath shower bed. The molding in the 1st stall in the second-floor Central Bath was repaired on 6/7/25. The build-up of unknown debris and hair in the 1st stall second-floor Central Bath shower was removed on 5/9/25. Visible water on the floor inside and outside the second-floor Central Bath shower stall was removed on 5/9/25. The housekeeping staff were re-educated in daily responsibilities to clean showers and to report any cleaning concerns to their director. The nursing staff was re-educated to remove all personal items after showers on 6/9/25. The maintenance staff was alerted to evaluate drainage in the second-floor shower. ELEMENT TWO: IDENTIFICATION OF AT RISK RESIDENTS: All residents have the potential to be affected by this practice. ELEMENT THREE: SYSTEMIC CHANGES: Leadership makes weekly rounds to check on cleanliness of showers. The process for requesting maintenance work was reviewed and staff re-educated. Maintenance and housekeeping issues are discussed at daily operation meetings. The Licensed Nursing Home Administrator reviews and acts upon issues reported. ELEMENT FOUR: QUALITY ASSURANCE: Root cause analysis was conducted and a QAPI performance improvement project team formed to address maintenance and housekeeping concerns. The housekeeping director/nurse leadership designee will conduct weekly rounds to inspect the cleanliness, neatness, and functioning of showers. Maintenance will be notified to correct any repairs needed. Findings of rounds shall be reported to the Licensed Nursing Home Administrator weekly for 3 months. The findings and actions taken will be reported to the QAPI committee for review and further direction as appropriate. DATE OF COMPLIANCE: June 9, 2025