Cluttered, Unsanitary Shared Room Compromises Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment for two residents whose room became cluttered and unsanitary. One resident, admitted in January 2026 with hemiplegia and hemiparesis following cerebrovascular disease, required assistance with personal care and had a care plan identifying risk for falls and impaired mobility, with an intervention to maintain a clutter-free environment. This resident’s daughter reported that during a visit the room was cluttered with multiple boxes and was very unsanitary, and she requested a room change. Photos and video from that visit showed multiple brown boxes stacked in front of the residents’ beds and along the path to the bathroom, personal items piled on the boxes, an empty box on a wheelchair, two white towels and an empty soda can near a power cord in front of the television, and overripe bananas and other personal items in front of one bed. The second resident, admitted in November 2025 with congestive heart failure, COPD, muscle weakness, difficulty walking, and a need for assistance with personal care, also had a care plan identifying risk for falls related to impaired mobility, with an intervention to maintain a clutter-free room. This resident recalled that the room had been cluttered with many boxes and was not clean during the prior week, and stated that staff did not explain the purpose of the boxes. The resident expressed dislike of the cluttered and unclean condition and stated that staff should have tidied and cleaned the room so it would be safe. Multiple staff interviews confirmed the cluttered and unsanitary condition of the room and acknowledged it was inappropriate. A housekeeper, after viewing the photos and video, stated staff should have tidied and cleaned the room and that the clutter could cause an accident. A nurse explained that the third roommate was moving out and packing personal items, which led to the accumulation of boxes, but agreed the room should not have been left cluttered and unsanitary due to resident safety and infection control concerns and that the environment was not homelike for the other two residents. Another nurse stated it was acceptable for the moving resident to have personal items but not to the extent of compromising roommates’ space, and noted the clutter could cause infection control and safety issues, especially in emergencies. A CNA stated the roommates had the right to a clean, home-like environment and that she would speak up if she saw such clutter. Another nurse reported seeing the room cluttered and unsanitary, describing it as unsafe and a potential fire hazard. The administrator acknowledged that the family requested a room change because the room was cluttered and unsanitary and affirmed residents’ rights to a safe, clean, and homelike environment, consistent with the facility’s homelike environment policy requiring a clean, sanitary, and orderly setting.
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