Failure to Maintain Cleanliness and Timely Linen Changes for Residents
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations and interviews. One resident's room was found to have dark debris, dried food particles, and dried sticky fluid on the floor, which had reportedly been present for at least two weeks. Both a housekeeping technician and the director of environmental services confirmed the room's unclean condition and acknowledged that resident rooms were supposed to be cleaned daily, but this had not occurred. Another resident, who is dependent on staff for total care due to a history of stroke and has a BIMS score of 15, reported that their bed linens were not changed regularly, typically only every couple of weeks. Over several days, surveyors observed the resident's bed linens to be visibly stained, soiled, and containing skin debris, food particles, and a urine-soaked incontinence pad. Despite the facility's policy to change linens on shower days and when soiled, the resident's sheets remained unchanged for several days, as confirmed by both the resident and staff interviews.