Failure to Maintain Cleanliness and Sanitation in Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents, as evidenced by unclean water cups and persistent strong odors of urine and stool. One resident with severe cognitive impairment, functional bladder incontinence, and total dependence for toileting and showers was found to have a water cup on her dresser containing a black substance identified as mold, along with floating debris and film in the water. The resident was unaware of the location of her water cup, and staff confirmed the presence of mold. Dietary staff were responsible for cleaning water cups, but there was no documentation of cleaning practices. Additionally, a strong odor of urine and stool was observed in the hallway outside the same resident's room. The resident reported her incontinence brief had not been changed during the night, and staff confirmed that while her brief was changed in the morning, her bed sheets, which were saturated with urine and soiled with stool, had not been changed. Facility policy required a clean, sanitary, and comfortable environment, including clean bed linens and pleasant scents, but these standards were not met.