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F0584
D

Failure to Maintain Clean and Homelike Environment for G-Tube Dependent Resident

Holyoke, Massachusetts Survey Completed on 06-10-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a clean and homelike environment for one resident who was dependent on a G-tube for nutrition due to severe dysphagia and other medical conditions. Multiple observations revealed that the resident's room, specifically the area around the G-tube feeding equipment, was not properly cleaned. The EnteraFlo pump, IV pole, corkboard, wall, and headboard near the resident's bed all had dried brownish colored splatter marks, indicating a lack of cleaning following a spill of nutritional supplement. The facility's policy required spot cleaning of vertical surfaces and IV poles, but these areas remained visibly soiled over several days. Interviews with nursing staff, housekeeping, and the administrator confirmed that the soiled areas should have been cleaned either immediately by staff or by housekeeping, but this was not done. There was also confusion among staff regarding responsibility for cleaning the G-tube pump and surrounding areas. The deficiency was identified through direct observation, record review, and staff interviews, all of which confirmed that the environment was not maintained in accordance with facility policy and resident rights.

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