Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for four out of six sampled residents by not ensuring the cleanliness of walls, feeding pumps, and privacy curtains. Observations revealed that the walls behind the headboards of two residents were stained with black spots, which appeared to be dried feeding tube formula. Additionally, feeding pumps used by two residents were found with black and brown spots, also resembling dried formula. Privacy curtains in the rooms of three residents were similarly soiled with black and brown dried spots. Resident records indicated that several of the affected individuals had significant medical needs, including diagnoses such as dysphagia, cerebral infarction, dementia, and gastrostomy status. Some residents were noted to have severe cognitive impairment and were totally dependent on staff for activities of daily living, while others required supervision or assistance. One resident without cognitive impairment specifically stated that his privacy curtain was dirty and had not been changed, expressing a desire for a clean living space. Interviews with staff, including a Licensed Vocational Nurse, housekeeping personnel, the housekeeping supervisor, and the Director of Nursing, confirmed that it was the facility's responsibility to keep feeding pumps, curtains, and walls clean. Staff acknowledged the presence of visible dirt and dried formula on these surfaces and recognized the importance of maintaining cleanliness to provide a safe and homelike environment. Review of facility policies indicated that curtains should be cleaned when visibly soiled and that wall washing was part of the housekeeping schedule.