Failure to Maintain Clean and Safe Resident Room Environment
Penalty
Summary
A deficiency was identified when a resident's room was not maintained in a safe, clean, and comfortable condition as required by facility policy. The resident, who had diagnoses including dementia, end-stage renal disease on hemodialysis, heart failure with pericardial effusion, COPD, and anxiety, and who had experienced multiple falls due to weakness, reported that housekeeping staff did not clean the room daily and that the floor had been sticky for several days. Direct observation by the surveyor confirmed the presence of sticky floors, brown stains, dirt, and debris near the bed, in the corners, and behind the recliner. The resident pointed out a food spill that had remained for several days, and after housekeeping staff mopped the floor, the surveyor noted that the sticky condition and debris persisted, especially in areas not moved or cleaned under furniture. Interviews with housekeeping staff and the housekeeping manager revealed that staff were trained to recognize environmental hazards such as spills and sticky floors and were expected to move furniture and thoroughly clean all areas, including under beds and behind recliners. Despite this, the cleaning performed was incomplete, and the floor was not cleaned according to policy or training. The housekeeping manager confirmed that the floor was not cleaned to expectations and required re-cleaning. Other staff, including CNAs, indicated that floors should always be clean and that they had received training on environmental hazards, but the deficiency persisted in this instance.