F0584

E

Failure to Maintain Clean and Sanitary Resident Rooms and Restrooms

Richmond, Texas Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment, specifically by not thoroughly cleaning and sanitizing resident rooms and restrooms in the 100 hall. For one resident with severe cognitive impairment, osteomyelitis, diabetes with neuropathy, muscle weakness, and frequent incontinence, and another resident with severe cognitive impairment, Alzheimer’s disease, heart failure, and occasional incontinence, surveyors observed their shared restroom on multiple occasions. The restroom contained a pink latex glove on the floor beside the toilet and a toilet seat riser with a dry brown substance on the seat, later identified as feces. These conditions were observed both when the residents were out of the room and when they were present, and the feces remained on the toilet seat riser over several observations.

Two additional residents, one with intact cognition but dementia, diabetes, polyneuropathy, and muscle weakness, and another with moderate cognitive impairment, diabetes, CKD stage 3A, anemia, and muscle weakness, were also found to be living in an unclean environment. Their shared room had crumbs and a white plastic spoon on the floor, and the restroom toilet bowl had a dried brown substance. A pair of soiled briefs was observed on the restroom floor in the corner. A family member of one of these residents reported that every time she visited, the room was dirty, the bed was not made, and the resident’s clothes were on the floor, and that she often ended up cleaning the room herself, sometimes finding the room dirty even when visiting twice in one day.

Interviews with housekeeping staff and facility leadership confirmed that housekeeping staff were responsible for cleaning resident rooms and restrooms, sanitizing tables, cleaning toilets, and removing trash, and that CNAs shared responsibility for removing trash and bagging soiled briefs. The housekeeper assigned to the 100 hall acknowledged that trash and soiled clothing lying around in resident rooms could be hazardous and could lead to infection. The housekeeping supervisor and DON stated that housekeeping staff did not clean when food was being served on the hall and that some rooms required cleaning twice a day, with CNAs expected to notify housekeeping when residents removed dirty briefs. Despite these stated responsibilities and policies, including a homelike environment policy requiring cleanliness and order, the observed conditions in the four residents’ rooms and restrooms demonstrated that the facility failed to ensure thorough cleaning and sanitation.

The facility’s homelike environment policy dated October 2009 stated that residents are to be provided with a safe, clean, comfortable, and homelike environment, including cleanliness and order. However, the persistent presence of feces on toilet surfaces, dried brown substances in toilet bowls, soiled briefs on restroom floors, and general room clutter and debris showed that this policy was not effectively implemented in the affected rooms on the 100 hall.