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F0584
E

Failure to Maintain Clean and Sanitary Resident Rooms

Mount Horeb, Wisconsin Survey Completed on 09-15-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a safe, clean, comfortable, and homelike environment for multiple residents, as evidenced by direct observations and resident interviews. Several rooms were found to be unclean, with one resident's room containing dried substances, crumbs, and what staff identified as fecal matter on the outside of the toilet that had reportedly been present for over a month. Additional observations included trash bags containing dirty linen and personal protective equipment left on the floor, and floors with visible debris and dried spills. Residents reported that housekeeping did not clean their rooms regularly, with some stating their rooms were cleaned only once a week or less frequently. Staff interviews confirmed the lack of regular cleaning, with a CNA acknowledging that not all rooms could be cleaned daily and the Housekeeping Supervisor citing insufficient staffing to complete all necessary cleaning tasks. The facility's own policy required regular cleaning and disinfection of resident rooms, but this was not consistently followed. There was also a lack of systematic communication with residents regarding their housekeeping concerns, as the Housekeeping Supervisor did not participate in resident council meetings to address such issues.

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