Failure to Maintain Clean, Sanitary, and Homelike Resident Room Environment
Penalty
Summary
A deficiency was identified in one resident room where the environment was found to be unclean, unsanitary, and not homelike. During observation, the room had a persistent urine odor, approximately seven flies were present, with some crawling on a sleeping resident and in a cup of juice. A sock was found on the bedside table, and the bedside commode contained a small amount of dark yellow urine. In the bathroom, a dried, dark brown substance, identified by staff as likely feces, was smeared on the toilet with flies crawling on it, and a puddle of dark yellow liquid was observed on the floor and trash can liner. Staff interviews revealed that the commode basin was not cleaned after each use as required, and there was uncertainty about when the bathroom was last cleaned. The two residents occupying the room both had diagnoses including dementia and required assistance with toileting due to decreased mobility, weakness, and incontinence, as documented in their care plans. Staff interviews confirmed that standard procedures, such as using liners in the commode and cleaning after each use, were not consistently followed. Housekeeping staff were unclear about cleaning responsibilities, and the facility did not have a specific policy for providing a homelike environment, although it was stated as a mission. The deficiency was cited under 3.1-19(f)(5) and related to a specific complaint investigation.