Failure to Maintain Clean, Homelike Resident Rooms and Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean, safe, and homelike environment in resident rooms and common areas, as required by its own policies. For one resident with osteomyelitis, muscle weakness, unsteady gait, and a need for assistance with personal care, surveyors repeatedly observed an IV pole with thick, crusted yellow dried liquid on the bottom and wheel coverings over several days. The same resident’s fitted bed sheet had maroon and dark brown stains and smears, crumbs were present along the baseboards and behind the dresser, and the resident’s clothing was stored in a clear trash bag. The resident reported that the sheets had never been changed since admission and described the room as filthy, stating the crusted liquid had been on the IV pole since it was brought into the room. Another resident, admitted with cellulitis of the left lower limb and lymphedema, was found over multiple days to have used, stained towels in the corner of the room and used washcloths and towels on the bathroom floor. A grocery bag full of trash was tied to the nightstand, and the fitted bed sheet had brown smears and yellow stains. This resident stated that sheets had never been changed since admission, that staff said they would change the sheets but did not follow through, and that towels in the room had been left by the Wound Nurse the prior week. The resident indicated a desire to clean the room personally but was unable to do so. Staff interviews showed inconsistent understanding of responsibilities: CNAs reported sheets were changed on shower days and clothing should be in closets, while housekeeping staff stated nursing changed sheets and that towels and trash should be removed during room cleaning, with medical equipment cleaning referred to supervisors. Additional observations documented unclean and poorly maintained common areas and equipment. On the 3rd floor terrace, the fire extinguisher cabinet had a large, unidentifiable white stain on multiple dates, and shower rooms contained wet towels on the floor and stained washcloths left in sinks and stalls over repeated observations. The elevator floor had dark, sticky stains on several days, with residents’ and staff’s shoes audibly sticking, and nearby walls and artwork had unidentifiable red splatter and large white stains. The 3rd floor dining room had multiple cracked or broken double windows, some unable to close fully, and one window partially covered by a large piece of cardboard; a handrail outside a resident room was loose and moved when touched. A resident room was repeatedly observed with dirty floors, trash wrappers, and a large dust-like splatter in the bathroom. The loop main hallway was repeatedly noted to have strong odors of urine, sweat, and bowel movement, sticky floors, visible trash, an open dirty linen cart emitting odor, and bags of visibly soiled linens and incontinence products on the ground. The Director of Housekeeping stated housekeepers were responsible for resident rooms and floor technicians for hallways and room floors, and acknowledged the hallway cleaning machine was broken, while the Administrator and DON stated their expectation that rooms, hallways, linens, and equipment be clean and properly stored.
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