Failure to Maintain Clean and Sanitary Resident Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for its residents, as evidenced by observations and staff interviews. One resident with impaired cognition and dependent on staff for bathing and hygiene was observed sitting in a wheelchair with a stained cushion, food particles in the seams, and rails and footrest pegs covered in a white substance and dried food. Staff confirmed the wheelchair was dirty and stated that while the night shift usually cleaned wheelchairs, they would clean them if visibly soiled. The facility's cleaning schedule indicated wheelchairs were to be cleaned weekly, but this was not adhered to in this instance. Another resident, also with impaired cognition and dependent on staff for personal hygiene, was found to have a navy-blue wall padding next to their bed that was smeared with a dried brownish material. Multiple observations over the course of a day showed the soiled padding remained uncleaned despite several staff entering and exiting the room to provide care. A CNA confirmed the presence of the dirty substance but did not take action to clean it or alert other staff. The soiled mat remained unaddressed until the following day when housekeeping staff cleaned it. Facility policy required all personnel to report and address unclean or defective equipment and furnishings, but this was not followed in these cases.