Failure to Maintain Clean and Sanitary Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and sanitary environment for its residents. In one instance, a resident was found in a room with a strong odor of urine, a wet and soiled incontinence pad on the bed with dried yellowish-brown stains, and multiple gnats present on the soiled area. Additionally, wet soiled clothes were found on the floor outside the bathroom, and soiled linens were left across the room. The resident reported being left in the wheelchair for an extended period without the area being cleaned, and a CNA confirmed that the night shift had left the room in that condition for several hours. The resident's care plan indicated a need for one to two staff assistance with all ADLs and noted incontinence of bowel and bladder. In another case, a different resident's room and the surrounding hallway had a strong urine odor, and the floor was sticky. The bed had an exposed incontinence pad with dried urine and feces, and the bedside table was sticky with dried spills and debris. Staff interviews confirmed that the resident, who had a urinary catheter and moderate cognitive impairment, would empty the catheter bag without assistance, often spilling urine on the floor and bed sheets. The resident also exhibited behaviors such as refusing housekeeping or personal care, requiring staff to clean the room after the resident left. Facility policies required prompt removal of soiled linens and maintenance of a clean, odor-free environment, which was not followed in these instances.