Failure to Maintain Clean, Safe, and Homelike Resident Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment in resident rooms, common areas, and a shower room. Surveyors observed that one resident’s privacy curtain was dangling from the track with 23 hooks not attached; the resident reported that staff had pulled the curtain causing the hooks to come off and that they had requested repair about a week earlier. In the dining area, a large brown spill, described by the housekeeping manager as looking like coffee, was found on a table where two residents were seated; the substance was partially dried and adhered to the table, requiring scrubbing and leaving a stain. In another resident’s room, a brown smeared substance that a CNA described as looking like feces or food was present on the wall, floor, and dresser. On the 700 unit shower room, surveyors found multiple environmental and safety issues: double sinks with white residue, a countertop with dried orange substance and food debris, a large pile of soiled toilet paper with a brown smeared substance on the floor next to the toilet, broken ceramic tiles around the shower drain with missing pieces, a missing shower head, a wet soiled washcloth hanging from a shower chair, and a razor left on the tub. The health information manager confirmed the presence of soap, food, white residue, and what appeared to be feces, and acknowledged that staff should monitor residents while in the shower room. In another room, human feces were observed on the floor next to the bed of a resident with dementia and severe cognitive impairment (BIMS score of 6); the housekeeper stated they had not yet gotten to that room and were unsure what the substance was but would clean it. Facility documents, including the housekeeping aide job description and the safe and homelike environment policy, state that housekeeping and maintenance services are to maintain a sanitary, orderly, and comfortable environment and that resident rooms and bathrooms are to be wet mopped daily, which was not reflected in the observed conditions.
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