Failure to Maintain Clean and Comfortable Resident Rooms
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by observations, interviews, and record reviews. During an initial tour, several unmade beds were observed, with some lacking linen and others containing soiled linen. One cognitively intact resident reported that staff did not make the bed daily, left dirty dishes in the room, and did not change sheets after providing bed or sponge baths. The resident's family member corroborated these findings, noting trash, used gloves, napkins, dirty dishes with old food, flies, and dirty linen present in the room during a visit. Another resident, who is severely cognitively impaired and dependent on staff for activities of daily living, was found in an unmade bed with the top sheet touching the floor and multiple used glasses and meal covers with thickened liquids left in the room. Staff interviews confirmed that beds should be made in the morning and dirty dishes removed after meals, but these tasks were not completed as required. Resident council meeting minutes from several months documented ongoing complaints about inadequate housekeeping, unclean floors, lack of clean linen after showers, and bedside tables not being cleaned, as well as certified nurse aides not making beds.