Failure to Maintain Clean, Homelike Environment and Control Odors
Penalty
Summary
Facility staff failed to maintain a clean and sanitary environment for a resident with a history of stroke and severe cognitive impairment. Multiple observations over two days revealed that the resident's room contained unopened condiment packages, food wrappers, dust, and a fall mat that was sticky and covered with food debris. Despite the facility's policy requiring daily cleaning and immediate attention to visibly soiled surfaces, these conditions persisted across several observations. The director of housekeeping confirmed that the room and fall mat were not clean during a walkthrough. Additionally, staff failed to provide a homelike environment free of lingering urine odors on one of the facility's units. Repeated observations in the memory care unit detected strong, stale urine odors in specific hallways over two consecutive days. The director of housekeeping described the cleaning protocols, which included daily cleaning, weekly floor scrubbing, and deep cleaning of two rooms per day, but acknowledged that lingering urine odors were present and not homelike. The odors were attributed to bathrooms, and efforts were made to assign dedicated housekeeping staff to the unit. Interviews with staff confirmed awareness of the cleaning routines and the presence of odors, with the activities assistant noting that minimizing odors depended on both resident care and housekeeping efforts. The executive director and director of nursing were informed of the findings, and no additional information was provided before the survey exit.