Failure to Maintain Clean and Comfortable Resident Environment
Penalty
Summary
The facility failed to provide a clean and comfortable environment for three residents, as evidenced by multiple observations of uncleanliness and lack of proper housekeeping. During a visit, a complainant observed spots and streaks resembling blood and saliva on the wall next to a resident's bed, dirty floors, and a broken bed. Subsequent inspection by facility leadership revealed numerous brown spots and streaks on the door frame, sticky and discolored hallway handrails, visible dust and debris beneath the sink, and a streaked mirror. The paper towel holder was dusty and stained, and the floor behind the door and at the end of a resident's bed was covered with lint, dust, scraps of paper, and various colored streaks. Additional findings included dust-covered junction boxes, dusty bedframes, debris under beds, maroon streaks on a structural encasement, dusty baseboards, and call light boxes with visible dust. Some areas, such as the room's general clutter and odor, were found to be acceptable, and all beds were functional at the time of inspection. Interviews with facility staff confirmed the lack of adequate cleaning. The Administrator-in-Training acknowledged being notified by a resident's family about the room's condition, including unclean walls and floors and the presence of belongings from a previous resident at the time of admission. She admitted that thorough cleaning had not occurred prior to the new admission and that she did not personally inspect the room after instructing staff to remove the previous resident's belongings. The facility Administrator stated that rooms should be deep cleaned when a resident leaves and before a new admission, with daily cleaning ongoing, and that a contracted housekeeping service was used, with oversight by administration and nursing leadership. The Environmental Services Department Supervisor confirmed that the accumulated dust, debris, and streaking observed in the residents' room were unacceptable and indicated that the areas had not been recently cleaned. The residents involved had significant cognitive and physical impairments, including severe neurocognitive disorder, anoxic brain injury, and spastic cerebral palsy, with all three having severely impaired cognition or communication abilities. The failure to maintain a clean and comfortable environment was directly observed and corroborated by staff interviews and record reviews.