Failure to Maintain Clean and Sanitary Mattresses for Multiple Residents
Penalty
Summary
The facility failed to provide a clean, sanitary, and homelike environment for five residents, as evidenced by the presence of whitish grime, stains, and dried matter on their mattresses. Observations revealed that mattresses used by residents with significant medical needs, such as tracheostomies, tube feedings, and ventilator support, were visibly soiled. For example, one resident's mattress had whitish grime on the bottom left portion, while another's had whitish stains and dust-like powder on multiple areas. Additional mattresses were noted to have yellowish dried matter, brownish drip-like stains, and powder-like grime. Interviews with staff, including a CNA and the housekeeping supervisor, confirmed that both nursing and housekeeping staff were responsible for cleaning and sanitizing mattresses after care or spills. However, there was a lack of immediate cleaning following spills, and some staff expressed discomfort cleaning around medical equipment, leading to unaddressed stains and grime. One resident, who was cognitively intact, reported that her mattress was dirty and that no one had come to clean it, expressing a preference for a clean mattress. Record reviews indicated that the facility had policies in place requiring daily cleaning of patient rooms and emphasized the importance of infection control and maintaining a homelike environment. Despite these policies, the observed conditions and staff interviews demonstrated that cleaning and sanitizing practices were not consistently followed, resulting in unsanitary mattresses for multiple residents with complex medical conditions.