Failure to Maintain Clean, Sanitary, and Homelike Environment Due to Housekeeping and Linen Deficiencies
Penalty
Summary
Surveyors observed multiple failures in the facility's maintenance, housekeeping, and linen services, resulting in an environment that was not clean, sanitary, or homelike. In the main dining room, a plastic table with accumulated food residue and debris was found, and trash containers were not emptied in a timely manner, leading to foul odors. Tablecloths on several tables were stained with food residue. The Food Services Director and Certified Dietary Manager confirmed these issues, noting that housekeeping was responsible for trash removal and kitchen staff for changing linens. In resident rooms, surveyors found soiled gowns left in showers, debris on floors, and strong urine odors, particularly in a shared room with four beds. Two residents in this room were totally dependent on staff for care, and one was observed lying on a mattress with a large wet spot and a persistent urine odor. Staff reported a lack of incontinence pads, resulting in urine soaking through sheets and into mattresses. Threadbare sheets were also observed in use. Laundry carts on all units lacked incontinence pads, and only a few were found in the laundry area. The Housekeeping Director acknowledged that pads should have been available but cited being pulled in different directions as a reason for the shortage. Interviews with residents and staff revealed concerns about reduced housekeeping staff on weekends, leading to delays and lower cleaning standards. The Housekeeping and Maintenance Directors were unsure about the replacement of odorous mattresses and agreed with the surveyors' findings upon inspection. The Director of Nursing stated that cloth incontinence pads were intended for all beds, but they were not consistently available. Photographic evidence was obtained to document the use of threadbare linens and the lack of incontinence pads.