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F0584
E

Failure to Maintain Clean and Homelike Shower Rooms

Portola, California Survey Completed on 07-24-2025

Penalty

Fine: $19,135
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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, safe, and homelike environment in three of three resident shower rooms, as evidenced by multiple observations of inadequate maintenance and cleanliness. Surveyors found paint chipping from walls and ceilings, missing paint and rust on door jambs, and rust on bolts, screws, and nuts securing tubs and toilets to the floor. In one shower room, a dry, flaky substance, possibly shampoo, was found spilled and dried on the bottom shelf of an open cupboard, with clean towels stacked on top. The foot of the bathtub and the area around the toilet were also unclean. Used razors were observed protruding from an almost full sharps container, and used hard bristle brushes intended for floor cleaning were left hanging on shower safety handrails in multiple rooms. Staff interviews confirmed the observations, with a CNA stating that the hard bristle brush should not be left on the handrails where residents could come into contact with it, and that the rooms were not maintained to acceptable standards. Both a licensed nurse and the assistant director of nursing acknowledged that the shower rooms were not adequately maintained or clean. The director of nursing also confirmed these findings upon review of the rooms and photographic evidence. The facility's own policy required cleaning and disinfecting of shared equipment and areas between each use, which was not adhered to in these instances.

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