Discussion

In this study, objects in rooms of residents with ADRD were significantly less likely to be adequately cleaned in nursing homes. Reasons for this may stem from the fact that individuals with ADRD may be less able to identify failures in room cleaning and less likely to advocate for themselves. This makes it easier for overworked staff to clean those rooms less adequately. In addition, individuals with ADRD may exhibit untoward behavior toward nursing-home staff, ^{Reference Soto, Andrieu and Nourhashemi6} resulting in intentional and unintentional preferences by cleaning staff to minimize time in rooms of residents with ADRD.

Importantly, tracking UV marker removal during the first winter wave of the COVID-19 pandemic identified extreme deficiencies in room cleaning, with only 7% of objects cleaned after daily cleaning, and only 29% after 7 daily cleaning attempts. This finding may be attributed to the impact of the COVID-19 pandemic, during which nursing-home employees were severely affected by the lack of resources and staffing, fear, and other psychological tolls of the pandemic. ^{Reference White, Wetle, Reddy and Baier7} Cleaning staff may be disproportionately affected by the pandemic due to their lower educational level, common language barriers, and lack of dedicated training limiting their comfort and aptitude cleaning in COVID-19 designated areas. Cleaning staff are often disproportionately affected by short staffing due to socioeconomic situations such as high-density housing, which is predisposed to COVID-19 cases and outbreaks. ^{Reference Parker, Bruckner and Vieira8} Nevertheless, even after controlling for COVID-19 designation, rooms were generally poorly cleaned, and the association of poorer cleaning and ADRD persisted. Furthermore, even prior to the COVID-19 pandemic, Murphy et al ^{Reference Murphy, Eells, Quan, Kim, Peterson, Miller and Huang9} reported that only 129 (22%) of 577 UV markers were removed by daily cleaning, compared to 7% in this study. Thus, broad efforts are needed to improve nursing-home cleaning.

An ADRD diagnosis is present in 47.8% of nursing home residents, ³ and many more have prediagnostic conditions. Ensuring that basic processes, such as room cleaning, are performed, regardless of the cognitive ability to assess or advocate for one’s condition, is essential to nursing-home care. Active efforts are urgently needed to support not only general training for nursing-home environmental cleaning but also to understand barriers and solutions to cleaning rooms of residents with ADRD. These efforts will need to include oversight of workers because it is easier to perform less thorough cleaning in those rooms. They will also need to address the barriers to thorough cleaning, including insufficient staffing, insufficient allotted time to complete the required job, insufficient wages (that produce pressure to work multiple jobs which leads to exhaustion), and fear of entering rooms that may be associated with unpleasant verbal or physical responses or abuse due to ADRD. ^{Reference Soto, Andrieu and Nourhashemi6,Reference Edward, Ousey, Warelow and Lui10}

This study had several limitations. Our capture of ADRD status did not include severity. Reasons cleaning deficiency were not determined. In addition, sampling was not randomized, although rooms were only sampled once. Nursing homes were also geographically limited to a large southern California county and may not be generalizable to other nursing homes.

In summary, rooms of individuals with ADRD are significantly less likely to be properly cleaned in nursing homes. Efforts are urgently needed to ensure the high quality of cleaning in nursing homes in general, and in rooms of residents with ADRD, in particular. UV markers may provide an effective feedback measure for cleaning process.