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F0689
D

Failure to Maintain Resident Room Free of Accident Hazards Due to Excessive Clutter

Glendora, California Survey Completed on 12-30-2025

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

A deficiency was identified when a resident's room was observed to be excessively cluttered, with multiple boxes, clothing, bags, food, drinks, and personal grooming items scattered around the bed and on the floor. The call light cord was found on the floor and not within the resident's reach. These conditions were noted during an observation and interview, where the resident stated that the facility would not assist with moving boxes to storage or provide additional boxes for organizing belongings. The resident had a history of bilateral primary osteoarthritis of the knees, COPD, anxiety disorder, and personality disorder, but was assessed as having intact cognition and the capacity to make medical decisions. The Minimum Data Set indicated the resident required setup or clean-up assistance with several activities of daily living. Despite this, the room remained cluttered, and the resident had refused deep cleaning services, as documented in housekeeping and nursing progress notes. Social services had previously discussed the hazards of the clutter with the resident, but there were no further documented interventions or encouragement to address the issue in the following months. The resident's care plan included goals to maintain a safe and clean living area and interventions such as encouraging the resident to organize belongings and offering staff assistance with cleaning. However, the care plan interventions were not effectively implemented, as the clutter persisted and the environment remained hazardous. Facility policies required a safe, clean, and homelike environment, but these standards were not met in this instance.

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