Failure to Maintain Clean Environment and Wheelchairs
Penalty
Summary
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment for residents, as evidenced by persistent strong foul odors of urine throughout the North and South units and unclean wheelchairs for multiple residents. Observations and interviews with residents, family members, and staff confirmed that the odor was present in resident living areas over multiple days, and both nursing and housekeeping staff acknowledged the ongoing issue. The Director of Nursing also confirmed the presence of the odor during the survey. Additionally, the facility failed to ensure that residents' wheelchairs were clean. Three residents who used wheelchairs were observed to have wheelchairs with thick coatings of grime, dust, dirt, dried spills, food particles, and unidentified stains. Residents and family members reported that staff did not clean the wheelchairs, and staff interviews confirmed that cleaning was supposed to occur on shower days and as needed, but this was not being done. The affected residents had various diagnoses, including cognitive impairment, muscle weakness, hemiplegia, and Parkinson's disease.