Failure to Maintain Cleanliness and Safe Environment for Residents
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and safe environment for multiple residents receiving enteral nutrition and for a resident with a damaged sink in her room. Two residents with orders for tube feeding were found to have dried, beige-colored formula splatter on their IV poles, feeding pumps, the floor, and an oxygen concentrator over multiple days. Despite a staff meeting agenda noting that nursing staff were responsible for cleaning up tube feeding spills and housekeeping for mopping, the enteral feeding equipment and surrounding areas remained unclean. The facility's policy required routine cleaning and disinfection of high-touch surfaces, including IV poles, but this was not followed as evidenced by repeated observations of unclean conditions. Additionally, a resident's room was found to have a sink with a large crack and sharp, elevated edges, as well as a broken support brace, making the sink unstable. The resident reported that the sink had been in this condition since she moved into the room and that she used it daily. Both the Maintenance/Housekeeping Director and the Administrator confirmed the hazardous condition of the sink upon observation, but were previously unaware of the issue. Staff members who regularly cleaned or provided care in the room also stated they had not noticed the broken sink. These failures resulted in an environment that was not safe, clean, or homelike, as required by facility policy and resident rights.