Failure to Maintain Clean Rooms and Adequate Linens for Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain clean, sanitary, and homelike resident rooms and linens for two residents. One resident with chronic kidney disease, diabetes mellitus, heart failure, and anxiety, who had intact cognition and was dependent on staff for hygiene and transfers, was observed in bed with dirty bed linens draped over his wheelchair, dirty incontinence wipes on the floor beside his bed, and a bed pad with creams and medications on the corner of his tray table. His recliner had a white powdery substance on the back and seat. The resident stated these items were left by midnight shift staff who did not remove the dirty items from his room. A psychotherapist present for at least 30 minutes confirmed no staff had entered the room during that time. A CNA who entered the room acknowledged the presence of the dirty wipes, soiled linens, and incontinence care items on the tray table, and stated the soiled linens had not been there when she provided care earlier. She removed items and cleaned the room but did not clean or disinfect the tray table before later placing the resident’s lunch tray on it, and she confirmed she had not properly cleaned the tray table prior to serving the meal. The resident further reported that staff did not clean his room before leaving and that agency staff did not know how to do their job. The second resident, admitted and re-admitted with diagnoses including psychotic disorder with delusions, hemiplegia, and quadriplegia, and with intact cognition, was observed with four pillows behind her head without pillowcases. She confirmed she had no pillowcases and wanted them but did not know why they were missing. A CNA confirmed the lack of pillowcases and attributed it to the midnight shift forgetting them. Later, an RN confirmed the pillows still had no pillowcases and stated CNAs refused to provide care. On a subsequent day, the resident had four pillows under her head, with only two covered by pillowcases and two plastic pillows without cases; she reported staff had run out of pillowcases. Two CNAs stated the floor supply closet did not have enough pillowcases for the resident’s pillows. However, observation of the second-floor linen supply closet showed three pillowcases available, and a laundry aide showed a laundry cart with approximately seven or eight folded pillowcases and stated the facility had an appropriate number of linens, including pillowcases, and that a linen cart was sent to the floor twice daily. These conditions conflicted with the facility’s Homelike Environment policy requiring a clean, sanitary, orderly environment and clean bed and bath linens in good condition.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.