Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for several residents, as evidenced by persistent odors of urine and fecal matter in resident rooms and hallways. Observations on multiple occasions revealed strong, unpleasant odors in various areas, including the entry hallway and several resident rooms. Residents and their families reported that rooms were not cleaned regularly, dirty linens and briefs were left in rooms, and family members sometimes had to clean the rooms themselves. These conditions were corroborated by direct observation and interviews with staff and residents. Several residents affected by these deficiencies had significant medical histories, including conditions such as gastroparesis, constipation, neuromuscular dysfunction of the bladder, Parkinson's disease, dementia, and recurrent urinary tract infections. Care plans indicated that some residents required total or moderate assistance with activities of daily living and had specific needs for skin care and infection control. Despite these needs, the facility did not consistently maintain cleanliness or address odors, and care plans were sometimes incomplete or not fully implemented. Interviews with housekeeping and nursing staff revealed concerns about inadequate staffing and increased workload, particularly after the implementation of weekend rotations. Staff reported being overwhelmed and unable to keep up with daily cleaning tasks, leading to unclean environments and persistent odors. Multiple staff members and a family member confirmed that the facility was only cleaned thoroughly when investigators were present, and that complaints about cleanliness had been voiced to administration without resolution.