Failure to Maintain Clean, Safe, and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment on multiple units and in several resident rooms. Facility policies required regular cleaning and disinfecting of housekeeping and environmental surfaces, yet surveyors observed a white PVC snack cart near the nursing station on the Riverside unit with dried brown liquid, crumbs, and dust on the bottom shelf, and a Hoyer lift in a hallway alcove with dried debris and dust on its base and in crevices. The Lead Housekeeper acknowledged the cart was an old snack cart that should not be there and should be cleaned, and stated there was no clear knowledge of how often equipment was power washed. The Maintenance Director reported there was no set schedule for cleaning equipment such as Hoyer lifts and that they only tried to do it quarterly. In one resident room, surveyors repeatedly noted a strong odor of urine and feces and found four used briefs, a dirty hospital gown, and an empty ginger ale can on the floor of the resident’s closet over multiple days without change. The resident reported that these items had been on the closet floor for four days. The same resident also reported that the left wheel of her wheelchair had been held in place with zip ties, string, and cloth for months, and observations confirmed the wheel remained secured in this makeshift manner on several occasions. The Maintenance Director stated he was not aware of any maintenance issues in that room and had not been informed of the loose wheel. In another resident room, the overhead light cover had fallen off and was observed leaning against the wall on multiple days, with the resident stating that the cover had come off a couple of weeks earlier and expressing relief that it had not fallen over her bed. The Maintenance Director confirmed there was no work order in the QR code system for that room and that he was unaware of the issue. Additionally, a different resident’s bathroom was repeatedly observed to have an offensive odor and a plastic wash basin filled with dirty towels and water sitting on the shower stall floor over several days, despite various housekeeping staff, CNAs, and nurses entering the room. An LPN confirmed the condition of the bathroom and stated that the resident sometimes threw items there and that housekeeping would be notified. Interviews with the DON and Administrator indicated an expectation that all staff help keep rooms clean and that anyone with a phone could submit maintenance work orders via QR codes, but staff appeared to misunderstand or not consistently use this process.
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