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F0584
E

Failure to Maintain Clean and Homelike Environment for Residents

Madera, California Survey Completed on 06-10-2025

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

The facility failed to maintain a safe, clean, and comfortable environment for two residents when their wheelchairs were observed to be covered with black and brown unknown substances. Both residents were found lying in bed asleep during the observation, and their wheelchairs, which were visibly soiled, were accessible and visible to passersby. The Assistant Director of Nursing (ADON) confirmed that housekeeping staff were responsible for cleaning the wheelchairs weekly, but this was not done. The ADON also acknowledged that the substances on the wheelchairs could be a source of bacterial growth and potentially cause illness. Housekeeping staff confirmed that the wheelchairs had not been cleaned the previous week due to staffing problems and agreed that unclean equipment could lead to illness. The Director of Nursing (DON) and the Administrator both stated that wheelchairs were expected to be cleaned weekly and as needed, and that all staff were responsible for ensuring a clean and homelike environment. Review of facility policy and job descriptions confirmed the expectation for maintaining cleanliness and a homelike environment. The failure to clean the wheelchairs as scheduled resulted in a violation of the residents' rights to a comfortable and homelike environment, as well as a potential source of infection.

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