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F0921
E

Failure to Maintain Clean and Sanitary Environment in Resident Areas

Indianapolis, Indiana Survey Completed on 12-09-2025

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 maintain a clean and sanitary environment across three of four hallways observed, specifically Hallways A, B, and D. Multiple resident rooms and shared bathrooms were found with significant cleanliness issues, including soiled floors, walls, handrails, and bedding. Observations included dried dark substances on walls, dirty and sticky floors, soiled sheets, and personal items mixed with debris. Bathrooms shared by residents were repeatedly found with feces, urine, and other waste on toilets, floors, and sinks, as well as stagnant urine and strong odors. In several cases, these unsanitary conditions persisted over consecutive days without being addressed, despite being reported by residents or their families. Housekeeping staff were inconsistently present or absent from the hallways during observations, and cleaning tasks were not completed as required. The Housekeeping Supervisor and other staff interviews revealed that there was confusion and lack of cooperation between nursing and housekeeping departments regarding responsibility for cleaning up messes, particularly those involving bodily waste. Housekeeping schedules showed limited staffing, with only two or three housekeepers assigned to cover all areas, and no check-off lists were used to verify completion of cleaning tasks. Management staff were expected to perform daily rounds and report issues, but the Executive Director was unaware of the extent of the cleanliness problems due to lack of reporting and personal verification. Residents affected by these deficiencies included individuals with limited mobility, incontinence, and those requiring assistance with activities of daily living. Some residents reported that their rooms had not been cleaned for extended periods, and family members expressed concerns about the unsanitary conditions. The facility's cleaning policies outlined specific procedures for daily and restroom cleaning, but these were not consistently followed, resulting in persistent unsanitary conditions in resident rooms, shared bathrooms, and common areas.

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