Failure to Maintain Cleanliness and Environmental Safety for Residents
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for several residents, as evidenced by multiple observations and interviews. One resident with an indwelling urinary catheter and neurogenic bladder experienced a severe plumbing issue in their bathroom, resulting in brown water and fecal matter overflowing onto the floor. Despite the resident reporting the issue and being instructed by nursing staff to use alternative means to empty their catheter, the bathroom remained soiled and uncleaned overnight. Staff interviews confirmed that the bathroom was not cleaned promptly, and there was confusion regarding responsibility for cleaning and maintenance notification. Another resident, who uses a manual wheelchair and is cognitively intact, was observed multiple times sitting in a visibly dirty wheelchair with food crumbs, dust, and clumps of hair. The resident expressed dissatisfaction with the cleanliness of the wheelchair and reported never seeing staff clean it. Staff interviews revealed there was no established cleaning schedule for wheelchairs at the time, and responsibility for cleaning was unclear among staff members. Additional deficiencies were noted in the cleanliness of another resident's room, where trash and debris accumulated behind furniture and on the nightstand, contrary to the facility's housekeeping checklist. Furthermore, five residents with personal mini refrigerators in their rooms did not have temperature logs or evidence of routine temperature monitoring, despite storing perishable items such as milk and yogurt. Interviews with staff and residents indicated a lack of clarity and consistency regarding which department was responsible for monitoring refrigerator temperatures, and some residents reported that temperatures had not been checked for extended periods.