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F0584
E

Failure to Maintain Clean and Safe Shower Rooms

Lake Jackson, Texas Survey Completed on 12-23-2025

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 residents by not maintaining cleanliness and organization in all three shower rooms (A-Hall, B-Hall, and C-Hall) reviewed. Observations revealed multiple issues, including a leaking shower head faucet in A-Hall, discolored floor and wall tiles, and the presence of dirty briefs, used linens, and overfilled trash cans in B-Hall. Items such as loose gloves, unfolded towels, exposed wipes, leaking and uncapped shaving cream containers, and a razor with a blood-like substance were found scattered and improperly stored. In C-Hall, a loose floor tile protector and a damp face towel left on a shower chair were noted. These conditions remained unchanged during follow-up observations later the same day. Interviews with staff indicated that CNAs were responsible for cleaning the shower rooms after use, but this was not consistently done. One CNA admitted to not cleaning the shower room after use due to being called away to assist with meal trays and forgetting to return. Other staff, including the Assistant Director of Nursing (ADON), Administrator (ADM), and Housekeeping Supervisor (HS), acknowledged the importance of maintaining cleanliness for infection control and resident dignity but were unaware of the ongoing issues until brought to their attention. The Maintenance Director stated he had not been informed of the leaking faucet in A-Hall and found no maintenance requests for it, although a repair was eventually made. Record reviews showed that the daily shower room checkoff list was not properly completed on the day of the observations, and the facility's policy required cleaning and disinfecting shower rooms after each use and daily at minimum. Despite these policies, the observed deficiencies in cleanliness, organization, and maintenance of the shower rooms were not addressed in a timely manner, resulting in an environment that did not meet the required standards for resident care and safety.

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