Widespread Environmental Uncleanliness and Poor Housekeeping Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, orderly, and homelike environment in resident rooms, shared bathrooms, hallways, and common areas, as well as inadequate housekeeping response to visible soil and bodily substances. Multiple cognitively intact residents reported dissatisfaction with the cleanliness of their rooms, including one resident whose window had a long streak of old tape and residue that had been present since admission, and another who had tied bags of soiled linens and trash left on the floor near her bed along with trash and debris under and around the beds. Other residents’ rooms were observed with visibly soiled floors, paper and food debris, dust and trash accumulations under beds and along walls, and soiled floor mats with dried stains that remained unchanged over multiple days. In one room, a large dried spill or stain was present on the floor near dialysis equipment, and a wall gouge was noted near the bed. Additional observations showed that several residents with dementia, cognitive communication deficits, and muscle weakness were living in rooms with dirty floor mats, crumbs and debris in mat seams, and stained walls adjacent to their beds. Shared bathrooms between resident rooms were repeatedly observed with unflushed urine in toilets, brown smears and splatters resembling fecal matter on toilet seats, bowls, walls, and floors, sticky/tacky floors, dust and debris around perimeters and baseboards, deteriorated grip strips that were torn and peeling, and darkened buildup or damaged caulk around toilet bases. These unsanitary conditions persisted across multiple observations on different days, including one bathroom that continued to have dirt, debris, stale urine odor, sticky floors, and dried brown splatter resembling fecal matter on and around the toilet despite prior similar findings. The memory care unit and spa/shower rooms were also found in unclean condition. In the locked memory care unit, surveyors observed heavy accumulations of dust and debris at double doors, in the dining room corners and along walls, and on wall-mounted fan blade guards, with these accumulations remaining unchanged on subsequent days. Hallways outside resident rooms contained trash, broken plastic pieces, and large dust balls. In spa and shower rooms, there were dust and dead bugs in the bottom of a spa tub, brown crusted debris on a shower chair, dozens of small ants on the floor emerging from floor junctures, and white wet debris resembling toilet paper on another shower chair. During a confidential resident council meeting, most residents present reported that rooms and shared spaces were not consistently kept clean and some reported bedding was not changed frequently enough. The Ombudsman reported ongoing complaints from residents and families about facility cleanliness over several months. Housekeeping staff stated that only two housekeepers were responsible for cleaning all resident rooms and the locked unit daily, and described a process in which CNAs were expected to clean visible bowel movements and urine before housekeeping would disinfect, while a CNA acknowledged leaving a resident unsupervised in the bathroom and not returning to assist with cleanup after toileting.
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