F0584

D

Failure to Provide Clean, Prepared Room for New Admission

Fresno, California Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment for a newly admitted resident. The resident, an adult female admitted for short‑term rehabilitation after a traumatic fall with multiple pelvic and lumbar fractures and recent pelvic fixation surgery, arrived at the facility by medical transport after an eight‑hour ambulance ride. She reported that, despite the facility having more than 24 hours’ notice of her admission, she was placed in a bed that still had used linens and a blanket from the prior resident, with a pillow containing used tissues underneath. She also reported that the bedside drawer and closet contained the previous resident’s personal belongings and that the room’s floor was dirty with sticky residue. The resident stated she was transferred into this bed and remained there for a couple of hours before clean linens were provided and housekeeping cleaned the room.

Interviews and observations by multiple staff and another resident corroborated key aspects of these concerns. The Director of Staffing Development acknowledged that the closet and bedside drawer had not been emptied after the prior resident’s discharge and that the floor cleanliness issue was addressed only after the new resident complained. The DSD explained that the bed had been on hold for the previous resident until midnight and that the new resident was admitted to that bed around 6:20 a.m., but she could not verify whether the bed and linens were dirty at the time of admission. The Infection Prevention Nurse stated that she learned the resident was very upset about the dirty bed and sticky floor and confirmed that having dirty floors and beds was not acceptable and could be a potential source of infection. The Business Manager confirmed seeing sticky residue on the floor later that morning and acknowledged that the resident reported belongings from the previous resident in the bedside drawer, though he did not personally inspect the storage areas.

Additional interviews further supported that the room and storage areas were not properly prepared before the resident’s admission. A roommate stated she witnessed the new resident being placed in a dirty bed that still contained the prior resident’s belongings and that the closet, drawer, and bed all had items from the previous resident, whose bed was being held. Housekeeping staff described the facility’s usual room turnover process, in which CNAs are expected to strip the bed and remove personal belongings so housekeeping can disinfect the bed, clean the floor, and clean storage areas once emptied. One housekeeper, who worked the morning of the admission, stated that when she entered the room after the resident’s arrival, the resident complained about a dirty bed, dirty floor, and belongings in the closet and drawer; the housekeeper observed sticky material on the floor and then cleaned the room. Another RN acknowledged seeing items in the closet and directing a CNA to empty it for the new resident’s use. The administrator later stated that if a bed was on hold, personal belongings and drawers would not be cleared and housekeeping would not clean those areas, but the bed itself should still be cleaned after transfer or discharge, and he conceded that this admission was an unusual circumstance and that staff may not have realized the previous resident’s belongings needed to be removed before admitting the new resident.

The facility’s own policies required a safe, clean, sanitary, and homelike environment, including clean bed and bath linens, and emphasized resident dignity, respect for private space and property, and maintenance of a safe, sanitary, and comfortable environment to prevent and manage transmission of infections. Despite these policies, the resident was admitted to a room where the bed, linens, floor, and storage areas were not confirmed to have been cleaned or cleared between residents, and multiple interviews confirmed that personal belongings from the prior resident remained in the closet and bedside drawer at the time of admission. These actions and inactions led to the cited deficiency related to the resident’s right to a safe, clean, comfortable, and homelike environment and to receiving treatment and supports for daily living safely.