Failure to Maintain Clean and Sanitary Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and sanitary environment in the West Resident Unit. In Room W-16, a large amount of a white substance from an incontinent brief was found strewn under and around a bed, with the floor showing liquid stains, visible dirt, and paper debris. A fall mat was propped against the bathroom door frame and was visibly soiled with dark liquid stains and dirt. Additional rooms, W-9 and W-11, were also noted to have dried liquid stains and dirt on the floors. A resident was observed seated in a wheelchair outside her room with a brown liquid substance on her clothing, wheelchair seat, and tires. Multiple large puddles of the same brown liquid were present under the wheelchair and extended along the floor. The resident reported having a bowel incontinence episode, activating her call bell, and waiting more than fifteen minutes for assistance. Staff interviews revealed that the nurse aide assigned to the resident had to leave due to an emergency, and other aides were occupied with their assigned tasks. The DON confirmed that all resident care and common areas are required to be kept clean and sanitary.
Plan Of Correction
1. Rooms W 8, 9, 11, & 16 including floors and any fall mats, were deep cleaned. Incontinence care was provided to Resident # 12 on 10/4/25. Resident # 12 w/c seat and wheels were cleaned. 2. EVS supervisor to complete an initial audit of all resident rooms, fall mats, and wheelchairs to ensure cleanliness. Any items identified as not clean will be cleaned. 3. EVS supervisor with provide education to housekeeping staff on room cleanliness standards. 4. EVS Supervisor or designee will complete room audits 3 x week for cleanliness of flooring, fall mats and chairs. Audits will be completed 3 x week x 4 weeks, then weekly x 4 weeks. Results of audits will be reviewed at facility QAPI committee.